Pediatric Transplantation Committee Fall 2014

Ongoing Committee Initiatives Pediatric Transplant Training and Experience Peds experience not required for key personnel in programs that transplant pediatric patients MANY attempts to resolve since 1993 - difficulty achieving consensus Spring 2014 regional presentation incorporated professional society and community feedback Slated for Jan 2015 Public Comment In the current Bylaws, pediatric experience is not required for surgeons or physicians to serve as key personnel at programs that transplant pediatric patients. The Committee has attempted to address this multiple times since 1993 and has had difficulty achieving consensus on appropriate requirements. We presented a modified proposal at the Spring 2014 Regional Meetings that included feedback from professional societies and the community, and we continue to work with these societies to gain support for this proposal. It is slated for Public Comment in January 2015.

Pediatric Kidney Component Qualifying Criteria Pediatric Primary Kidney Surgeon Meet current Bylaws for Primary Kidney Surgeon 12 Kidney transplants in patients younger than 18 Pediatric Primary Kidney Physician Meet Bylaws requirements outlined in one of the following sections of Appendix E (Membership and Personnel Requirements for Kidney Transplant Programs), Section E.3 (Primary Kidney Transplant Physician Requirements): 3.C (Three-year Pediatric Nephrology Fellowship Pathway) 3.D (Twelve-month Pediatric Transplant Nephrology Fellowship Pathway) 3.E (Combined Pediatric Nephrology Training and Experience Pathway) These proposed requirements have not changed since we presented them at the Spring 2014 Regional Meetings.

Pediatric Liver Component Qualifying Criteria Pediatric Primary Liver Surgeon Meet current Bylaws for Primary Liver Surgeon 18 liver transplants in patients younger than 18 Pediatric Primary Liver Physician Meet Bylaws requirements outlined in one of the following sections of Appendix F (Membership and Personnel Requirements for Liver Transplant Programs), Section F.3 (Primary Liver Transplant Physician Requirements): 3.C (Three-year Pediatric Gastroenterology Fellowship Pathway) 3.D (Pediatric Transplant Hepatology Fellowship Pathway) 3.E (Combined Pediatric Gastroenterology/Transplant Hepatology Training and Experience Pathway) These proposed requirements have not changed since we presented them at the Spring 2014 Regional Meetings.

Pediatric Heart Component Qualifying Criteria Pediatric Primary Heart Surgeon Meet current Bylaws for Primary Heart Surgeon 8 heart transplants in patients younger than 18 Pediatric Primary Heart Physician Meet current Bylaws requirements for Primary Heart Physician Care for 8 heart transplant patients younger than 18 years of age American Board of Pediatrics: Sub-board of Pediatric Cardiology Certification These proposed requirements have not changed since we presented them at the Spring 2014 Regional Meetings.

Pediatric Lung Component Qualifying Criteria Pediatric Primary Lung Surgeon Meet current Bylaws for Primary Lung Surgeon 4 lung transplants in patients younger than 18 Pediatric Primary Lung Physician Meet current Bylaws requirements for Primary Lung Physician American Board of Pediatrics certification in pulmonology medicine possessed by the individual who meets the current bylaw requirements OR another member of the lung transplant team. These proposed requirements have not changed since we presented them at the Spring 2014 Regional Meetings.

Additional Considerations Conditional Pathway Eliminate Alternative Pathway for Predominantly Pediatric Programs Use appropriate medical judgment for rare situations In order to safeguard access to transplant, the proposed Bylaws will contain a pathway for primary physicians or surgeons to acquire conditional approval. In order to acquire conditional approval, either the primary surgeon or primary physician must meet all the pediatric training and experience requirements in the proposed Bylaws. The other key personnel member still must meet minimal requirements. The individual with conditional approval will then have two years to fulfill the remaining requirements. The MPSC may consider giving that person a two year extension to gain the required experience. The Committee also agreed to eliminate the current Alternative Pathway for Predominantly Pediatric Programs if this proposal is approved. This pathway, which currently exists in the Bylaws for both surgeons and physicians of each organ program, has been used a limited number of times (less than 15) and would undermine our recommendations if it remained. One concern that has been raised is this proposal’s impact in an emergency situation when a child is too unstable to be transported to a hospital approved to transplant pediatric patients. In this rare instance, as in any situation not specifically addressed by OPTN Policy or Bylaws, surgeons and physicians should exercise appropriate medical judgment.

New Committee Initiatives Ethical Considerations for Pediatric Candidates NOTA and Final Rule require equitable allocation policy addressing special needs of children June 2010: Ethics Committee publishes white paper Jan-Sept 2014: Ped-Ethics Joint Subcommittee drafts companion paper--pediatric principles of organ allocation Slated for presentation to the Board in Nov 2014 The National Organ Transplant Act (NOTA) charges the OPTN to “recognize the differences in health and in organ transplantation issues between children and adults throughout the system and adopt criteria, policies, and procedures that address the unique health care needs of children.” The Final Rule requires that the OPTN develop policies for the “equitable allocation” of deceased donor organs, while also requiring that these policies achieve “best use” of the organs. In June 2010, the OPTN/UNOS Ethics Committee published “Ethical Principles to be Considered in the Allocation of Human Organs,” which presented utility and justice as the two ethical principles that must be balanced in order to achieve an equitable allocation system. In January 2014, a Joint Subcommittee of the Ethics and Pediatric Committees met to begin drafting a companion to this white paper, which will describe the ethical principles that should be considered in allocation to pediatric candidates. The Pediatric Committee will present this white paper to the Board in November 2014.

Questions? Eileen Brewer, MD Committee Chair ebrewer@bcm.edu Regional Rep name (RA will complete) Region X Representative email address Christine Flavin, MPH Committee Liaison christine.flavin@unos.org