OPTN/UNOS Kidney Transplantation Committee

1. OPTN/UNOS Kidney Transplantation Committee Fall 2017

2. Kidney Committee Update • SLK Allocation Policy Implementation • 2 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)

3. Implementation Update

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

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

6. 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-KASYear 1 to Post-KASYear2: • Post-KASYear 1: December 4, 2014 - December 3,2015 • Post-KASYear 2: December 4, 2015 - December 3,2016 • Pre-KAS: December 4, 2013 – December 3, 2014 6

7. Geographic Distribution of KidneyTransplants Post−KASYear1 Post−KAS Year2 25% 20% 17.5% 18.0% 15% 14.2% 13.5% 13.0% 12.7% 10.9% 10.2% 9.9% 9.7% 10% 7.8% 7.4% 7.2% 7.2% 6.7% 6.4% 6.4% 6.3% 5% 3.9% 3.8% 3.7% 3.4% 0% 1 2 3 4 5 6 OPTNRegion 7 8 9 10 11 No substantial changes in any region post−KAS Year 2 vs. post−KAS Year1.

8. Deceased Donor Transplants by RecipientAge Waitlist(11/30/2016) Post−KAS Year1 Post−KAS Year2 43.6% 40% 38.8% 37.2% 30% 27.9% 26.0% 24.4% 22.4% 19.5% 18.2% 20% 12.8% 12.0% 10% 8.6% 2.3% 2.3% 0.8% 0.7% 0.7% 0.7% 0.5% 0.2% 0.2% 0% 0−5 6−10 11−17 18−34 RecipientAge 35−49 50−64 65+ The percent of transplants to younger candidates (18−49) decreased slightly, and transplants to 50+ candidates increasedslightly.

9. Geographic Distribution of Pediatric KidneyTransplants Pre−KAS Post−KASYear1 Post−KAS Year2 50% 40% 30% 21.2% 20% 16.8% 15.8%16.7% 16.0%15.6% 14.7%15.0% 13.2% 10.0% 9.9% 9.8% 9.5% 9.5% 10% 7.1% 7.7% 7.6% 7.6% 7.7% 6.5% 7.4% 6.1% 5.9% 5.6% 5.6% 5.2% 5.0% 5.0% 4.1% 3.4% 3.9% 2.2% 2.9% 0% 1 2 3 4 5 7 8 9 10 11 6 OPTNRegion 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.

10. CPRA 99-100% Recipient “BolusEffect” 20 Percent of Transplants to CPRA 99−100% Recipients 17.7% 15.7% 15.4% 15 14.6% 13.4% 13.4% 12.6% KAS Implementation 12.4% 12.3% 12.2% 11.9% 11.8% 11.7% 11.2% 10.6% 10.5% 10.2% 10.1% 9.7% 9.5% 9.9% 9.6% 9.7%10.0% 10.1% 9.6% 10 5 3.5% 3.2% 2.9% 2.9% 2.5% 2.8% 2.4% 2.3%2.0% 1.8% 1.8% 1.6% 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 TransplantDate Transplants to CPRA 99−100% patients rose sharply after KAS but have tapered to around10%.

11. High Dialysis Time Recipient “BolusEffect” 20 18.6% 17.1% Percent of Transplants to Recipients with 10+ Years of Dialysis 15 KAS Implementation 12.4% 12.2% 11.1% 10 9.1% 8.9% 8.3% 7.7% 7.6% 7.5% 7.2%7.0% 6.8% 6.8% 6.7% 6.7% 6.2% 6.2% 6.0% 6.0% 5.7% 5.7% 5.6% 5.2% 5.2% 5.2% 5 4.5% 4.8% 4.6% 4.5% 4.3% 4.3% 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 TransplantDate Transplants to candidates with 10+ years of dialysis rose sharply after KAS but have tapered substantially to around6%.

12. Kidney Discard Rate byKDPI KASYear Pre−KAS Post−KAS Year1 Post−KAS Year2 59.3% 58.9% 60% 54.8% 66.8% 65.0% 60% 40% 40.2% 41.7% 40% 19.7% 18.5% 20% 17.1% 28.0% 28.4% 6.7% 6.4% 5.2% 19.8% 19.8% 2.7% 2.5% 2.5% 20% 16.2% 14.3% 0% 10.1% 11.8% 6.9% 7.8% 0−20 21−34 35−85 86−100 6.1% 4.7% 3.6% 3.7% 1.3% 1.7% 0% 0−10 11−20 21−30 31−40 41−50 51−60 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

13. Delayed Graft Function (DGF)Rates 27.7% 24.4% Percent Delayed Graft Function (DGF) 30%29.6% 20% 10% 0% Pre−KAS Post−KASYear1 Post−KAS Year2 KASYear 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).

14. Patient and Graft Survival -Overall 100% 100% KASYear Pre−KAS Post−KAS 95% 95% Patient Survival (%) Graft Survival (%) p−value:0.0727 p−value:0.0026 90% 90% 85% 85% 80% 80% 360 270 300 330 150180 210240 30 90 120 0 60 270 300 330 120 0 150180 210240 360 30 60 90 Time Post−Transplant(Days) Time Post−Transplant(Days)

15. 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

16. New Project

17. Concepts Under Consideration

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