MELD and UNOS James Trotter MD Baylor University

MELD and UNOS James Trotter, MD Baylor University Medical Center Dallas, Texas

U. S. liver transplant candidates

Liver transplants by year

Liver transplants by year listed transplants

Age of newly listed patients %

Newly listed patients > 65 y %

Newly listed patients MELD > 35 n

Percent liver-kidney transplants advanced age diabetes MELD score 3. 8[ln bili] + 11. 2[ln INR] + 9. 6[ln Cr] + 6. 4 year

Removed from list for death

Removed from list died on list removed, too sick

% died on list+too sick to transplant

MELD score Wiesner et al. Gastro, 2003 10(0. 957 ln(Cr) + 0. 378 ln(bilirubin) + 1. 12 ln(INR) + 0. 643)

high priority for waiting time list patients early in disease list fills with non-sick pts changes in 2002 sicker pts die waiting transplant of non-sick pts MELD-based liver allocation

high priority for sickness list sicker patients list fills with sick pts current many delisted as too sick to transplant of very sick pts long rehab poor fxnality reform is needed

Regional sharing – Share 35

Regional sharing – Share 35

Region 4 OKC DFW SAT HOU

Region 4 – prior sharing system Under old system, liver procured OKC locally offered to highest MELD DFW local pt, then to region. SAT HOU

Region 4 – current regional sharing Under new system, liver procured OKC locally offered to MELD > 35 local pt, DFW then to region MELD > 35. SAT HOU

Regional sharing of organs Pros - equalize transplant MELD and death rate - more equitable organ allocation Cons - longer cold time - more distance traveled - worse outcomes? - local donation impact - doesn’t “go far enough” - small center impact

Liver redistricting – new proposal • “if some is good, more is better” • wider regional sharing in the US • fulfills “Final Rule” – access to donors not limited by geographys • normalizes access/waitlist mortality • supported by: NYC, BOS, SFO, LAX

Liver redistricting – new proposal

Liver redistricting - concerns • long-travel times (logistics/cost) • penalizes good DSA’s, rewards laggards • effects of share-35 not fully assessed • worsen outcomes • not supported by: organ-rich, low-MELD regions: MO, KS, SC, TN, TX

Liver redistricting - proposal 110/12, 000 = 0. 9 % lives saved per year 58 DSA’s in US x 2 livers per year = 116 lives saved

Liver redistricting - summary • at Chicago meeting 80 % opposed • tabled for now • Spring 2015 conference to reconsider

ALLOCATION OF LIVERS BASED ON THE “SHARE 35” POLICY HAS NO IMPACT ON WAITING LIST MORTALITY AND WORSENS ORGAN UTILIZATION IN UNOS REGION 4 James F. Trotter Baylor University Medical Center

Background – Share 35 allocation • designed to "decrease wait list deaths and minimize distance traveled" of donor organs • its impact has not been reported • outcomes of liver transplant candidates and recipients before/after "Share 35" policy in the UNOS Region 4 (Oklahoma and Texas)

Region 4 – current regional sharing OKC DFW SAT HOU

Distance between region 4 cities • OK City – San Antonio • Amarillo – Houston • El Paso – DFW 422 533 573 • New York – Cincinnati • New York – Charlotte 568 532

Background – Share 35 allocation http: //optn. transplant. hrsa. gov/Public. Com ment/pubcomment. Prop. Sub_288. pdf

Methods • outcomes of – waiting list candidates on the waiting list – organ disposition – characteristics of liver transplant candidates – 6 m before (12/17/2012 – 6/17/2013) and after (6/18/2013 – 12/18/2013) "Share 35 "

Results Share 35 livers recovered, not recovered transplanted pre 269 12 257 post 321 30 291 change +52 (19 %) +18 (150 %) +34 (13 %)

Results Share 35 pre died 66 (10 %) too sick to transplant 120 (18 %) post 82 (12. 3 %) 97 (15 %) total 186 179

Results Share 35 regional organ share MELD >= 35 wait list death + too sick pre 9. 0 % 18. 3 % 28 % post 28. 5 % 32. 2 % 27 %

Results Share 35 CIT distance organ travelled procured organ discarded pre 6. 2 hrs 130 miles 4. 5 % post 6. 6 hrs 162 miles 9. 3 %

Summary – “Share 35 allocation” Although 19 % more livers were procured, there was no change in the percentage of patients removed from the list for death or too sick to transplant.

Summary – “Share 35 allocation” Despite predictions that “Share 35” would improve patient outcomes the opposite is true in UNOS Region 4. Consider these findings as proposals for even larger regional sharing policies are under review.