The Deceased Donor Kidney Allocation System

123,208 organ tx candidates are on the waiting list As of February 15… 123,208 organ tx candidates are on the waiting list 101,603 are waiting for a kidney tx

Overall Changes to Allocation System Waiting time calculation Pre-registration dialysis time added Candidate classification Estimated Post Transplant Survival Score (EPTS) Kidney donor classification Replace SCD/ECD with Kidney Donor Profile Index (KDPI) Candidates are eligible to receive waiting points for administration of ESRD dialysis that occurred prior to their being listed on the waitlist. All adult candidates have an Estimated Post Transplant Survival score, or EPTS. This score was designed to promote better longevity matching between donor and recipient in order to utilize the maximum amount of graft years post-transplant. Standard Criteria Donors (SCD) and Expanded Criteria Donors (ECD) are being replaced with a more refined metric known as the Kidney Donor Profile Index or KDPI.

Recent Allocation Component Changes Priority for sensitized candidates Calculated panel reactive antibody (CPRA) sliding scale, regional/national sharing for CPRA greater than 98% Pediatric kidney allocation KDPI priority Blood type eligibility A2 and A2B to B compatible Highly sensitized candidates get priority for kidneys through additional sharing and a sliding scale points system for calculated panel reactive antibody or CPRA scores. Greater access to deceased donor kidneys for blood type B candidates who can safely accept a kidney from an A2 or A2B blood type donor; and For pediatric candidates, priority will be based on the donor’s KDPI instead of the donor’s age.  

Candidate Priority Kidney candidate priority Priority points Match classification (position on the match run)

Sequence A Sequence B Sequence C Sequence D KDPI <=20% KDPI >20% but <35% Sequence C KDPI >=35% but <=85% Sequence D KDPI>85% Highly Sensitized 0-ABDRmm (top 20% EPTS) Prior living donor Local pediatrics Local top 20% EPTS 0-ABDRmm (all) Local (all) Regional pediatrics Regional (top 20%) Regional (all) National pediatrics National (top 20%) National (all) 0-ABDRmm Local adults Regional adults National adults Local Regional National Local + Regional These are the four allocation sequences for kidney allocation. The four sequences are based on the donor’s KDPI score.

Waiting Time Points Priority Dialysis start date Date after registration that eGFR is at or below 20 mL/mn 1 point for each year on the waiting list Tiebreaker is date of registration Peds begin accruing time at listing, receive credit for any pre-listing dialysis time *Peds begin accruing waiting time at listing regardless of clinical factors

Waiting Time Qualifiers Dialysis Determined by listing center Waittime may start prior to listing Multiple centers may have equal waittime points Acceptable methods of documentation 2728, dialysis center letter, physician note GFR/Cr Clearance Waittime can only start at or after candidate is listed Only one center can have longest waittime points Laboratory

Multiple Listing with Dialysis as the Waittime Qualifer Multiple DSAs listing Access to different local donor pool Completing with different candidates Multiple local listings Alternate clinical interventions available Different acceptance rates and parameters

Estimated Post Transplant Survival Current diagnosis of diabetes Time on dialysis Any prior solid organ transplant Candidate’s age All adult candidates receive an Estimated Post-Transplant Survival (or EPTS) score. The EPTS score is a numerical measure used in the new kidney allocation system to identify those candidates expected to live the longest after a kidney transplant.   Let’s review the factors included in the EPTS formula: candidate’s age time on dialysis whether or not the candidate has a current diagnosis of diabetes whether the candidate has had any prior solid organ transplant EPTS scores range from 0% to 100%. EPTS score range 0%-100%

EPTS Match Classification Priority EPTS score used to identify two groups of patients* Those with scores of 0-20% Those with scores of 21-100% *The top 20% EPTS is calculated based on a national pool of candidates from a certain time period. The EPTS score will be calculated based on the national pool of candidates, but it will only be used to identify two broad groups of candidates in that pool: those with scores of 20% or less, and those with scores exceeding 20%.   (Note: EPTS only identifies these two groups, but not rank order of candidates on the match.) Candidates with a lower EPTS score are expected to experience more years of graft function from high-longevity kidneys compared to candidates with higher EPTS scores. In general, candidates with lower EPTS scores tend to be of a younger age. Analysis has revealed that candidates in their mid-50s can still have EPTS scores in the Top 20%. Though candidates with diabetes tend to have higher EPTS scores, the same analysis showed that some younger diabetics have EPTS scores of 20% or less. Candidates who have had a prior solid organ transplant, as well as those having spent many years on dialysis, tend to have higher EPTS scores.

Kidney Donor Profile Index KDPI based on: Donor age Height Weight Ethnicity History of hypertension History of diabetes Cause of death Serum creatinine Hepatitis C virus status Donation after circulatory death Kidney Donor Profile Index (KDPI) KDPI is a numerical measure that combines ten dimensions of information about a kidney donor, including clinical parameters and demographics, to express the relative longevity of that donor kidney compared to the entire deceased kidney donor pool.   KDPI is calculated by using the donor variables of: Age Height Weight Ethnicity History of hypertension History of diabetes Cause of death Serum creatinine Hepatitis C status Whether the donor donated organ after circulatory death These factors are used to calculate a percentage score that is associated with how long a kidney offered is likely to function after transplantation based on a historical cohort of similar donated kidneys. The lower the KDPI the greater the likelihood that the kidney will have a longer time of function in the recipient. KDPI scores range from 0-100% Lower KDPI is associated with better longevity

Using the KDPI to Predict Graft Survival

EPTS & KDPI in the New System Longevity Matching EPTS 0-20% KDPI The intent of longevity matching is to ensure that kidneys expected to function the longest are most often transplanted into those candidates expected to live the longest, thereby realizing the greatest benefit from kidney transplantation.   Thus, the EPTS will be used in tandem with the KDPI to introduce the concept of longevity matching into the new allocation system. The EPTS score will only be used in kidney allocation when the donor has a KDPI of 0-20%. In other words, the EPTS will be used to prioritize candidates in only 20% of kidney allocations, while for 80% of allocations EPTS will not be used at all.

Candidate Points Report

National 20% EPTS OHOU Blood Type O candidates 48 candidates that fall within the 20%

Sequence A Sequence B Sequence C Sequence D KDPI <=20% KDPI >20% but <35% Sequence C KDPI >=35% but <=85% Sequence D KDPI>85% Highly Sensitized 0-ABDRmm (top 20% EPTS) Prior living donor Local pediatrics Local top 20% EPTS 0-ABDRmm (all) Local (all) Regional pediatrics Regional (top 20%) Regional (all) National pediatrics National (top 20%) National (all) 0-ABDRmm Local adults Regional adults National adults Local Regional National Local + Regional These are the four allocation sequences for kidney allocation. The four sequences are based on the donor’s KDPI score.

Sequence A KDPI <= 20% Highly Sensitized (CPRA 98+) 0-ABDRmm (0-20% EPTS) Prior living donor Local pediatrics Local (0-20% EPTS) 0-ABDRmm (21-100% EPTS) Local (21-100% EPTS) Regional Pediatrics Regional (0-20% EPTS) Regional (21-100% EPTS) National Pediatrics National (0-20% EPTS) National (21-100% EPTS) Candidates with EPTS scores of 0-20% will be prioritized ahead of candidates with lower scores, but only for the highest longevity kidneys, which are those that have a KDPI of less than or equal to 20%. What you see on this slide shows the allocation sequence of KDPI 20% or less kidneys. You can see that patients with an EPTS of 0-20% will receive priority for zero mismatches[animation], local offers[animation], as well as regional [animation] and national [animation] offers. It is also important to note that allocation proceeds first to local patients with EPTS of 0-20%, followed by local patients with EPTS exceeding 20%, before offers are made regionally or nationally.

CPRA score Based on unacceptable antigens listed for the candidate Used to calculate how many donors will be incompatible with the candidate Ranges from 0-100% Immune system sensitivity is assessed by the CPRA score.

CPRA Priority Points CPRA Sliding Scale (Allocation Points) 20 18 16 0.08 0.21 0.34 0.48 0.81 1.09 1.58 2.46 4.05 6.71 10.82 12.17 17.30 2 4 6 8 10 12 14 16 18 20 30 40 50 60 70 80 90 100 Points CPRA Sliding Scale (Allocation Points) (CPRA<98%) CPRA points are assigned based on a CPRA sliding scale, beginning at a CPRA score of 20%. Candidates with a CPRA from 80 to 84 receive about 2.5 points, while candidates with CPRA of 85 to 89 will receive just over 4 points. Candidates with CPRA’s in the high 90’s receive substantially more points: for example, candidates with CPRA scores of 99 and 100% will receive 50 and 202 points, respectively. CPRA CPRA

CPRA Match Classification Priority Sequence A KDPI <=20% Sequence B KDPI >20% but <35% Sequence C KDPI >=35% but <=85% Sequence D KDPI>85% Highly Sensitized 0-ABDRmm (top 20% EPTS) Prior living donor Local pediatrics Local top 20% EPTS 0-ABDRmm (all) Local (all) Regional pediatrics Regional (top 20%) Regional (all) National pediatrics National (top 20%) National (all) 0-ABDRmm Local adults Regional adults National adults Local Regional National Local + Regional CPRA greater than 98% In order to get priority, lab director and physician/surgeon must sign written approval of unacceptable antigens and this must be reported in UNet.

Pediatric Status Points Aged 0-10 at the time of the match run and 0-ABDR mismatch with donor = 4 points Aged 0-10 at the time of the match run and the donor’s KDPI is less than 35% = 1 point Aged 11-17 at time of the match run and a 0-ABDR mismatch with donor = 3 points

Pediatric Match Classification Priority Sequence A KDPI <=20% Sequence B KDPI >20% but <35% Sequence C KDPI >=35% but <=85% Sequence D KDPI>85% Highly Sensitized 0-ABDRmm (top 20% EPTS) Prior living donor Local pediatrics Local top 20% EPTS 0-ABDRmm (all) Local (all) Regional pediatrics Regional (top 20%) Regional (all) National pediatrics National (top 20%) National (all) 0-ABDRmm Local adults Regional peds Regional adults National adults Local Regional National Local + Regional *Pediatric match classification priority is based on age at the time of registration (not time of the match run)

Prior Living Organ Donors 4 points with every registration Prior living organ donors receive 4 points with every registration (for second or additional transplants).

Sequence A Sequence B Sequence C Sequence D KDPI <=20% KDPI >20% but <35% Sequence C KDPI >=35% but <=85% Sequence D KDPI>85% Highly Sensitized 0-ABDRmm (top 20% EPTS) Prior living donor Local pediatrics Local top 20% EPTS 0-ABDRmm (all) Local (all) Regional pediatrics Regional (top 20%) Regional (all) National pediatrics National (top 20%) National (all) 0-ABDRmm Local adults Regional adults National adults Local Regional National Local + Regional These are the four allocation sequences for kidney allocation. The four sequences are based on the donor’s KDPI score.

HLA-DR matching priority points A zero HLA-DR mismatch with the donor = 2 points A single HLA-DR mismatch with the donor = 1 point

HLA Match Classification Priority Sequence A KDPI <=20% Sequence B KDPI >20% but <35% Sequence C KDPI >=35% but <=85% Sequence D KDPI>85% Highly Sensitized 0-ABDRmm (top 20% EPTS) Prior living donor Local pediatrics Local top 20% EPTS 0-ABDRmm (all) Local (all) Regional pediatrics Regional (top 20%) Regional (all) National pediatrics National (top 20%) National (all) 0-ABDRmm Local adults Regional adults National adults Local Regional National Local + Regional

Rank-ordering of Candidates within each Match Classification Total points determined by: Waiting time CPRA sliding scale HLA-DR matching Pediatric status Prior living donor status Tiebreaker = date of registration Within each of the allocation categories discussed, these two EPTS groups, will be rank-ordered on the match by total allocation points. Remember that allocation points are determined by: time on dialysis, or time after meeting eGFR (glomerular filtration rate) or CrCl (creatinine clearance) criteria, the calculated PRA or CPRA sliding scale, HLA-DR matching, pediatric status, and prior living donor status. If a tie-breaker is needed, the date of registration will be used.

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Chrystal Graybill chrystal.graybill@unos.org 804-782-4631 Questions? Chrystal Graybill chrystal.graybill@unos.org 804-782-4631