Pancreas Committee Spring 2017

Committee Projects Maximum Allowable BMI for KP Waiting Time Broadened Allocation of Pancreas Transplants Across Compatible ABO Blood Types Anticipated for Fall 2017 Public Comment Guidance on Increasing Pancreas-After-Kidney (PAK) Transplants Maximum Allowable BMI for KP Waiting Time Anticipated for Spring 2018 Public Comment The Pancreas Committee is actively working on three separate projects. 1. Current blood type restrictions on kidney-pancreas allocation prevent clinically compatible SPK transplants from occurring. Preventing clinically compatible SPK transplants results in many of these pancreata being discarded or not recovered. The Committee intends to revise current blood type restrictions with the goal of increasing the number of simultaneous kidney-pancreas transplants and the number of utilized pancreata. The committee has utilized SRTR modeling to determine the effect of several new ABO scenarios on candidates (specifically kidney-alone and kidney-pancreas candidates). We plan to send this proposal out for public comment in Fall 2017. 2. Pancreas After Kidney (PAK) transplants have substantially declined for more than a decade. PAK transplants have dropped steadily each year, from 414 in 2004 to 68 in 2015. PAK transplantation has historically been associated with inferior pancreas allograft survival compared with Simultaneous Pancreas and Kidney (SPK) transplantation. For pancreas graft survival, the 1-year outcomes for SPK transplant (96.4%) compared to PAK transplant (87.3%) are similar, but at 5 years, the divide is greater for PAK (61.4%) compared to SPK outcomes (80.4%). Some single-center studies demonstrate better outcomes for PAK recipients, but the improvements have not been shown at the national level to date. The committee seeks to discover those characteristics that result in improved outcomes and address previous studies that demonstrate poor outcomes for PAK recipients. We are drafting a guidance document and plan to distribute it for public comment in Fall 2017. 3. Current policy requires that kidney-pancreas candidates who are on insulin, and with a C-peptide greater than 2 ng/mL, have a body mass index (BMI) less than or equal to the maximum allowable BMI to accrue waiting time. With the implementation of the new Pancreas Allocation System (PAS) in 2014, the maximum allowable BMI is reviewed every 6 months to determine whether it should be modified. The determination to either increase or lower the maximum allowable BMI is based on the percentage of active kidney-pancreas candidates that meet the waiting time criteria. The maximum allowable BMI at implementation of PAS was 28, and after 6 months it was raised to 30. Subsequent 6 month analyses have indicated the maximum BMI should be raised further, however, current policy states that the maximum allowable BMI cannot be modified to exceed 30. The Committee intends to perform further data analyses to investigate the effect of C-peptide and BMI on patient and graft survival to determine the appropriate policy regarding maximum allowable BMI. We are hoping to have a proposal prepared for the Spring 2018 public comment cycle.

Questions? Jonathan Fridell, MD Committee Chair jfridell@iupui.edu Matthew Prentice, MPH Committee Liaison Matthew.prentice@unos.org