OPTNUNOS Kidney Transplantation Committee Fall 2017 1 Kidney

OPTN/UNOS Kidney Transplantation Committee Fall 2017 1

Kidney Committee Update § SLK § 2 Allocation Policy Implementation Year KAS Data § Allowing Deceased Donor-Initiated KPD Chains Concept Paper § Improving Allocation of En Bloc Kidneys (Voting item) § Improving Allocation of Dual Kidneys (Voting item) 2

Implementation Update SLK Allocation • Primary Changes: SLK medical eligibility criteria, SLK allocation requirements, safety net for liver recipients registered on kidney waiting list within a year after liver transplant (effective Aug. 10). • New Waitlist fields available since May 31. • Visit https: //optn. transplant. hrsa. gov/learn/professional-education/ for policy and system training resources. 3

Implementation Update New Waitlist Reports determine candidate eligibility at their center: § “Kidney Priority for Liver Transplant Recipient” report § “Liver-Kidney (SLK) Candidate” report 4

The Kidney Allocation System (KAS) The First Two Years Prepared for OPTN Kidney Transplantation Committee April 19, 2017 Amber R. Wilk, Ph. D John Beck Anna Y. Kucheryavaya, MS United Network for Organ Sharing UNOS Research Department

Background Performance initially tracked monthly through June 2015 (“out of the gate” reports) ● Six month report completed September 2015 ● One year report completed April 2016 ● ● Two year analysis completed April 2017 ● Post-KAS years only, comparing Post-KAS Year 1 to Post-KAS Year 2: ● Post-KAS Year 1: December 4, 2014 - December 3, 2015 ● Post-KAS Year 2: December 4, 2015 - December 3, 2016 ● Pre-KAS: December 4, 2013 – December 3, 2014 6

Geographic Distribution of Kidney Transplants Post−KAS Year 1 Post−KAS Year 2 25% 20% 17. 5% 18. 0% 14. 2% 13. 0% 13. 5% 12. 7% 10. 9% 9. 7% 10. 2% 9. 9% 7. 4% 6. 4% 5% 3. 9% 3. 4% 3. 8% 6. 4% 6. 3% 7. 2% 6. 7% 7. 8% 7. 2% 3. 7% 0% 1 2 3 4 5 6 7 8 9 10 11 OPTN Region No substantial changes in any region post−KAS Year 2 vs. post−KAS Year 1. 7

Deceased Donor Transplants by Recipient Age Waitlist (11/30/2016) Post−KAS Year 1 Post−KAS Year 2 43. 6% 40% 38. 8% 37. 2% 30% 27. 9% 26. 0% 24. 4% 22. 4% 19. 5% 20% 18. 2% 12. 8% 10% 12. 0% 8. 6% 2. 3% 0. 2% 0. 7% 0. 2% 0. 8% 0. 7% 2. 3% 0. 5% 0% 0− 5 6− 10 11− 17 18− 34 35− 49 50− 64 65+ Recipient Age The percent of transplants to younger candidates (18− 49) decreased slightly, and transplants to 50+ candidates increased slightly. 8

Geographic Distribution of Pediatric Kidney Transplants Pre−KAS Post−KAS Year 1 Post−KAS Year 2 50% 40% 30% 21. 2% 20% 16. 8% 15. 8% 16. 7% 14. 7% 15. 0% 16. 0% 15. 6% 13. 2% 10. 0% 9. 9% 9. 8% 10% 7. 6% 5. 9% 4. 1% 5. 6% 2. 9% 2. 2% 9. 5% 7. 6% 7. 7% 7. 1% 7. 7% 7. 4% 6. 5% 6. 1% 5. 2% 5. 0% 3. 4% 3. 9% 0% 1 2 3 4 5 6 7 8 9 10 11 OPTN Region Post−KAS, most regions had higher or similar percent of pediatric transplants Year 2 vs. Year 1; regions 7, 10, and 11 had a decrease in pediatric transplants, while regions 1 and 8 saw increases. 9

CPRA 99 -100% Recipient “Bolus Effect” 20 15. 7% 15. 4% 15 14. 6% 13. 4% 12. 6% 10 12. 2% 11. 7% KAS Implementation Percent of Transplants to CPRA 99− 100% Recipients 17. 7% 12. 4% 11. 8% 12. 3% 11. 9% 11. 2% 10. 6% 10. 1% 9. 7% 9. 5% 9. 9% 9. 6% 10. 5% 10. 0% 9. 7% 10. 1% 9. 6% 5 3. 5% 3. 2% 2. 9% 2. 3% 1. 8% 2. 0% 1. 6% 2. 9% 2. 5% 2. 8% 2. 4% 1. 8% 0 Feb− 2014 May− 2014 Aug− 2014 Nov− 2014 Feb− 2015 May− 2015 Aug− 2015 Nov− 2015 Feb− 2016 May− 2016 Aug− 2016 Nov− 2016 Feb− 2017 Transplant Date Transplants to CPRA 99− 100% patients rose sharply after KAS but have tapered to around 10%. 10

20 18. 6% 17. 1% 15 KAS Implementation Percent of Transplants to Recipients with 10+ Years of Dialysis High Dialysis Time Recipient “Bolus Effect” 10 12. 4% 12. 2% 11. 1% 9. 1% 8. 9% 8. 3% 7. 7% 7. 6% 7. 5% 6. 7% 6. 2% 6. 0% 7. 2% 7. 0% 6. 8% 6. 7% 6. 2% 5. 7% 6. 0% 5. 7% 5. 6% 5. 2% 5 4. 3% 4. 8% 4. 6% 4. 5% 4. 1% 3. 3% 3. 6% 0 Feb− 2014 May− 2014 Aug− 2014 Nov− 2014 Feb− 2015 May− 2015 Aug− 2015 Nov− 2015 Feb− 2016 May− 2016 Aug− 2016 Nov− 2016 Feb− 2017 Transplant Date 11 Transplants to candidates with 10+ years of dialysis rose sharply after KAS but have tapered substantially to around 6%.

Kidney Discard Rate by KDPI KAS Year Pre−KAS Post−KAS Year 1 Post−KAS Year 2 60% 54. 8% 58. 9% 59. 3% 40% 20% 17. 1% 2. 5% 6. 7% 6. 4% 2. 7% 2. 5% 18. 5% 19. 7% 5. 2% 0% 0− 20 21− 34 35− 85 86− 100 66. 8% 65. 0% 60% 40. 2% 41. 7% 40% 28. 4% 20% 0% 1. 3% 1. 7% 0− 10 3. 6% 3. 7% 11− 20 6. 1% 4. 7% 21− 30 6. 9% 7. 8% 31− 40 10. 1% 11. 8% 41− 50 14. 3% 16. 2% 51− 60 19. 8% 61− 70 71− 80 81− 90 91− 100 KDPI (%) The overall discard rate increased from 19. 3% post−KAS Year 1 to 19. 9% post−KAS Year 2. KDPI 21− 34% kidneys saw a decrease in discard rate in the most recent year, while KDPI 35− 85% kidneys discard rates increased again. KDPI 0− 20% and 86− 100% remain fairly stable in the post−KAS era. 40

Delayed Graft Function (DGF) Rates 29. 6% 30% 27. 7% Percent Delayed Graft Function (DGF) 24. 4% 20% 10% 0% Pre−KAS Post−KAS Year 1 Post−KAS Year 2 KAS Year The percentage of recipients requiring dialysis within the first week after transplant decreased from 29. 6% post−KAS Year 1 to 27. 7% post−KAS Year 2, but remains higher than pre−KAS. The decrease was significant (p = 0. 0010). 13

Patient and Graft Survival - Overall KAS Year Pre−KAS 100% 95% Graft Survival (%) 95% Patient Survival (%) Post−KAS p−value: 0. 0026 90% 85% 80% 0 30 60 90 120 150 180 210 240 Time Post−Transplant (Days) 270 300 330 360 p−value: 0. 0727 90% 0 30 60 90 120 150 180 210 240 Time Post−Transplant (Days) 270 300 330 360

Highlights: First 2 years of KAS ● Many very highly sensitized and high dialysis time patients have been transplanted under KAS ● Transplants to these groups have tapered over 2 years ● Deceased donor transplant volume has increased ● Largest impact on pediatric transplants is still concentrated in Region 5 ● However, utilization of recovered kidneys has not improved ● DGF has increased but is slowly trending downward ● Post-KAS, 1 -year graft (94. 1%) and recipient (96. 2%) survival are excellent, though slightly lower than pre-KAS 11

New Project Allowing Deceased Donor-Initiated KPD Chains • Concept Paper with three models for allowing deceased donors to initiate KPD chains • Requesting feedback on proposed methods and feasibility • Available for comment on OPTN website 16

Concepts Under Consideration Candidate. Driven Model • FIRST: Candidate receives increased priority on Waitlist • THEN: Candidate is transplanted • THEN: Paired living donor donates List Exchange Chains Model • FIRST: Paired living donor donates • THEN: Paired candidate receives priority on Waitlist Donor-Driven Model • FIRST: Deceased donor organ redirected from Waitlist allocation to a specific KPD program and their matching priorities • THEN: KPD Candidate matched and transplanted • THEN: Paired living donor donates 17

Questions? Nicole Turgeon, MD Kidney Committee Chair nturgeo@emory. edu Amber Wilk, Ph. D Kidney Committee Research Liaison amber. wilk@unos. org Chelsea Rock Haynes, MPA Kidney Committee Liaison chelsea. haynes@unos. org Gena Boyle, MPA SLK Liaison gena. boyle@unos. org 18