Liver and Intestinal Organ Transplantation Committee

1. Liver and Intestinal Organ Transplantation Committee Spring 2017 Update

2. What problem does this address? • Significant variation in a candidate’s chances of receiving a liver offer depending on where the candidate is registered • Final Rule: “allocation policies must be based on sound medical judgment, seek to achieve the best use of donated organs, and shall not be based on the candidate’s place of residence or place of listing” except to the extent needed to satisfy other regulatory requirements

3. Recent Public Comment Proposals • Redesigning Liver Distribution Proposal - Fall 2016 • As planned, the Committee did not send proposal to Board in 2016 • Further evaluating8 Districts, Concentric Circles, and Neighborhoods

4. Public Comment Themes

5. Liver Distribution Options • 8 Districts • Optimized redistricting • Concentric Circles • Sharing to all transplant centers within a fixed distance from the donor hospital • Neighborhoods • Optimized DSA based sharing

6. 8 Districts (Fall 2016 proposal) • 8 districts • 150-mile radius, in-district* proximity circle • 3 MELD/PELD proximity points • No proximity points for Statuses • Adult donors: district-wide sharing for MELD/PELD ≥29 before introducing local (DSA) priority • Full redistricting for pediatric donors 150 miles, +3 points B A X D C *Organ at donor center X will first be offered to candidates at centers A and C, with center A candidates receiving 3 proximity MELD/PELD points. If organ is not accepted during district-wide allocation, organ will be offered to candidates at centers B and D, with center B candidates receiving 3 MELD/PELD proximity points.

7. Proposed 8 District Map for Liver Allocation Example of Proximity Circle: 5 5 8 2 3 3 7 1 4 6 *Meant to represent 150-mile radius circle. Not to scale.

8. Concentric Circles • Share livers with all transplant candidates registered at liver programs within a fixed distance of the donor hospital • If large enough, circles may significantly reduce geographic disparity • Currently used for thoracic organ distribution

9. DSA Neighborhoods • Neighborhoods are contiguous and build upon the current DSAs • 58 Neighborhoods – one for each DSA • Each Neighborhood contains groups of transplant centers based on a central donor center location

10. DSA Based Neighborhood Maps

11. Outcomes • All scenarios: • All scenarios reduce disparity in access to liver transplantation • Minimize effects of geography on transplantaccess • Better satisfy the Final Rule

12. Next Steps • Committee submitted an LSAM request to evaluate all 3 solutions using: • A post-share 35 cohort • A sharing threshold of 29 • 3 proximity points for candidates local to the donor • Two separate definitions of local: • 150 mile radius around donor hospital • DSA • LSAM results anticipated by April 30, 2017 • Committee will evaluate and determine whether any solution is ready for Fall 2017 public comment • The Committee has a goal to present a solution by December 2017 to the OPTN/UNOS Board of Directors

13. Other Relevant Projects • System Optimizations Project • OPO Committee is looking at reducing time limits for responding to organ offers • Changes to HCC Criteria for Auto Approval • Policy 9.3.F: Candidates with Hepatocellular Carcinoma (HCC) • Modify the HCC exception criteria to accurately reflect the disease severity of candidates’ by MELD score • Public comment August 15, 2016 to October 15, 2016 • National Liver Review Board (NLRB) • Structure and exception points assignment (currently out for public comment) • Guidance Documents (currently out for public comment)

14. Access to Information Information from the Liver and Intestines Transplantation Committee can be accessed through the OPTN website at: https://optn.transplant.hrsa.gov

15. Questions? Ryutaro Hirose, MD Committee Chair ryutaro.hirose@ucsf.edu Matt Prentice, MPH Committee Liaison matthew.prentice@unos.org