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SLK

SLK. Spring 2015. How will KAS be monitored?. Geography : are more kidneys being allocated outside of the local DSA? Unintended consequences : are fewer kidney patients being listed? has the number of transplants for any demographic or clinically specific groups changed unexpectedly?

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SLK

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  1. SLK Spring 2015

  2. How will KAS be monitored? • Geography: are more kidneys being allocated outside of the local DSA? • Unintended consequences: • are fewer kidney patients being listed? • has the number of transplants for any demographic or clinically specific groups changed unexpectedly? • how often are shipped kidneys for CPRA 99 & 100 patients discarded or redirected? Analysis schedule: 6 months, 1 year, annually

  3. Simultaneous Liver Kidney (SLK) Allocation Project The problem: • OPTN Final Rule requires allocation policies be: • based on sound medical judgment and standardized criteria • seek to achieve the best use of organs • avoid futile transplants • No standard rules or medical criteria specified in OPTN policy for SLK allocation • Current policy requires kidney to be allocated with liver if donor and candidate are in same DSA but does not specify rules for regional or national allocation • KAS and elimination of kidney payback system erased incentive for OPOs to share kidney with liver regionally

  4. Important Historical Background • 2006-2007—Societies hold consensus conference on the issue • 2009— Kidney and Liver Committees sponsor public comment proposal • Majority of regions, individual commenters, and other committees supported proposed changes • Varying concerns expressed from national groups (ASTS, NKF, AUA) • 2010—Committees decided not to move forward due to complex IT programming associated with proposal (mostly due to kidney allocation variances) and development of the new KAS • 2014—KAS is implemented, removing all variances

  5. Different Perspectives on the Problem • OPO community perspective: No consistent rules beyond local distribution means the OPO is left to make the decision • Liver community perspective: This inconsistency is counter to goal the regional ‘Share 35’ liver policy seeks to achieve • Kidney community perspective: Some medical criteria should be required to ensure that kidney is not allocated to a candidate who may regain kidney function after liver-alone transplant because this diverts access from a kidney alone candidate

  6. The Impact of the Problem by #’s

  7. 2015 SLK Working Group Recommendations

  8. Recommended SLK Eligibility Criteria

  9. Recommended SLK Allocation Policy • If candidate meets the eligibility criteria, the OPO must allocate the kidney with the liver if allocation is local or regional before offering the kidney to a kidney-alone candidate

  10. Data Reviewed for Safety Net Recommendations

  11. Recommended ‘Safety Net’ Policy • If, 2-12 months after a liver transplant, a liver recipient is registered for a kidney and: • has begun dialysis for ESRD or • has an eGFR at or below 20 mL/min • The candidate will receive additional priority on the kidney waiting list • Once the candidate meets this criteria, the candidate will continue to be eligible for additional priority.

  12. Next Steps • Seeking feedback from: • Regions • Professional transplant societies and national groups • Other Committees • Committees will reconvene in Spring to review feedback/finalize a public comment proposal for Fall 2015 • Explore and discuss application of these changes to heart/kidney and lung/kidney allocation

  13. Survival advantage of receiving a KIPurpose: Provide evidence supporting SLK eligibility criteria

  14. Crude survival advantage of receiving a kidney vs. liver alone p-value=0.0007 Recipient survival Recipient survival * Medians are shown Cohort: recipients Mar 31, 2002 – Dec 21, 2012

  15. KI graft survival for SLK vs. KI alone… and Heart-KidneyPurpose: Assess degree of decrease in kidney graft survival in multi-organ transplants

  16. Kidney graft survival Recipient survival Cohort: recipients Mar 31, 2002 – Dec 21, 2012

  17. Kidney graft survival Cohort: recipients Mar 31, 2002 – Dec 21, 2012

  18. The effect of a previous LI tx on KI waiting list and recipient survivalPurpose: provide evidence supporting the use of the safety net

  19. Kidney patient survival: with vs. without prior liver tx Waiting list survival Recipient survival Time period: Mar 31, 2002 – Dec 21, 2012

  20. Summary

  21. Predicting ESRD* after LI txIsrani, at al Am J Transplant 2013; 13: 1782–1792 Hazard function for ESRD (post MELD) Incidence of ESRD * Initiation of maintenance dialysis therapy, KI tx or listing for KI tx

  22. SLK Working Group • Kidney Transplantation Committee • Liver and Intestinal Organ Transplantation Committee • OPO Committee • Ethics Committee • Minority Affairs Committee • Operations and Safety Committee

  23. Achieving a Balance Access Utility

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