Kidney and Kidney/Pancreas Transplantation in a Year Reem Daloul, MD Assistant Professor of Medicine The Ohio State University

Transplantation Landscape in a Glance https://optn.transplant.hrsa.gov/

Kidney Transplant Trends The transplant numbers have been staggering despite growing waitlist for the last decade or so until 2014 when transplants finally started to see some increased growth Also, for the first time since transplant started, the numbers of patients on the deceased wait list, both active and inactive, has declined *OPTN/SRTR 2016 report

Transplant by Donor Type Break Down The Numbers Waiting List Kidney Liver Pancreas Kidney/Panc Heart Lung Intestine Candidate 94,954 13,773 876 1,628 3,951 1,465 254 Transplant by Donor Type 2017 2016 2015 2014 2013 2012 2011 All Donor 34,770 33,610 30,974 29,539 28,955 28,053 28,540 Deceased 28,588 27,630 24,985 23,720 22,967 22,187 22,518 Living 6,182 5,980 5,989 5,819 5,988 5,866 6,022

Transplant is Affected by the Opioid Crisis *OPTN/SRTR 2017 report

National Average Waitlist Time The average waiting time on the deceased list continues to be very variable between different donation service areas. This is mostly dependent on the OPO function. While the composition of the population in a specific DSA could affect rate of donation, the major drive for more or less eppears to be related to the OPO activity and how active/aggressive the OPO is in trying to obtain consent percentage of transplant within fiver years of listing per DSA

New KAS Allocation System In 2014, a new kidney transplant (KAS) allocation system was implemented Improve donor-recipient matching to improve graft longevity Increase access to disadvantage groups (highly sensitized, B blood group, minorities) Incorporated two new concepts; Kidney donor profile index (KDPI), scores from 0-100% Estimated post transplant survival (EPTS), scores 0-100% Changes to the points system Waiting time starts from dialysis date not listing date Priority to patient with cPRA >89% Allowed transplantation of A2 organs into B blood type

Short-Term Effects of new KAS; Bolus Effect *D. E. Stewart et al. AJT 2016

Short-Term Effects of new KAS, Racial Disparity After implementation of KAS, there has been increased number of tx among Hispanic and black. This is most likel due to increased credit given for time on dialysis before listing. However, disparity persists, especially in terms of living donation. *OPTN/SRTR 2017 report

Treatments Trends *OPTN/SRTR 2017 report Almost 75% of program use T-cell depletion mTORI use has dropped to about 4% Over 71% of program uses chronic prednisone *OPTN/SRTR 2017 report

What about Belatacept? No available date regarding trends of use yet Belatacept has been in shortage up until August of 2018 Its use continues to be explored in other organs including lung, heart, and combined K/P

Kidney Transplants Outcomes 51.6% 34.2% Risk for graft failure in Deceased donor recipient Risk for graft failure in living donor recipient *OPTN/SRTR 2017 report

ABMR As a Major Reason For Long Term Graft Failure *Sellares J. Am J Transplant 2012

Exploring New Venues!

Using HCV+ Donors!

Pancreas Transplant

Pancreas Transplant Trends Adults on the waiting list Dec 31 each year Pancreas transplantation rate has been steadily declining over the past decades and this is also reflected by less people on the wait list *OPTN/SRTR 2017 report

New Transplant Allocation System 2014 New allocation system: Allowed Type-II DM with BMI <30 Joined all types of pancreas transplant candidates in one list and treated them equally Pancreas Transplant Increase in Pancreas transplant is largely driven by increase in SKP transplant

Incentives for SKP Transplant Wait time is much shorter for SKP compared to kidney alone KDPI is usually lower reflecting high quality of donors whose pancreas is suitable for transplantation Pancreas transplant program are becoming more aggressive offering SKP to older patients and patients with higher BMI

Immunosuppression Trends *OPTN/SRTR 2017 report

Outcomes in Pancreas Transplant Graft failure within 90 days of transplant Acute rejection within first year post Transplant Outcomes reporting for pancreas transplant is not as straight forward as it is for kidney transplant. Mainly because up until 2017, there has been no concise definition of graft failure. So the definition varied from one center to the other. This makes it difficult to define long term outcomes but we can still look at some short terms outcomes such as patient survival and acute rejection rate 90 days graft survival over the last 5 years or so has been relatively stable around 8% form most kind of pancreas transplant. This in part reflect improved surgical technique and comfort with pancreas transplantation and probably better organ selection Similarly, risk for acute rejection in the first year have significantly improved *OPTN/SRTR 2017 report

Outcomes in Pancreas Transplant Patient death at 1 year Patient death at 5 years Patient death at 10 years *OPTN/SRTR 2017 report

Outcomes in Pancreas Transplantation Outcomes in pancreas transplant is dependent on center volume *T. Alhamad et al. Transplantation 2017

Summary Kidney transplant numbers has increased over the last 2 years This increase is attributed solely to an increase in deceased donor donation The kidney transplant field continues to explore new sources for organ donation, including donors infected with HIV and HCV viruses Pancreas transplantation has been overall on the decline for the last 10 years Simultaneous kidney pancreas transplant has shown some rebound in the last two years Outcomes of pancreas transplantation continues to improve but appears to be dependent on center volume

THANK YOU Reem Daloul