Anne L. Lally, MD Surgical Director of the Kidney Transplant Program Hartford Hospital

 Best policy at all times  Encourage them to talk to you

I heard about this guy who went to a party and woke up the morning in a bathtub full of ice. His kidneys had been stolen and sold on the black market.

 Urban Legends  Internet reaches far  No evidence of this occurring in the U.S.  Fear needs to be addressed  Reality

The rich and the famous get moved to the top of the waiting list, while regular people (like me) have to wait a long time for a transplant.

 Organ allocation blind to name, celebrity, or social status  What matters on the list is blood type, severity of illness and other medical information  Don’t forget : Walter Payton (NFL)

If I am in an accident and the hospital and doctors know I am a donor they will not try to save my life.

 When you come to the hospital the number one priority is to save your life.  Your team of doctors and the transplant team are separate  Once all lifesaving efforts have failed and death has been determined then the team coordinating the donation is notified

My religion does not approve of organ donation

 All organized religions support donation  It is seen as an act of charity and sharing God’s love in the Christian religions  Islam, Judaism, Buddhism, Hinduism – generally accepted but still some debate on the validity of the current brain death criteria

 Establish irreversible cause of coma  Achieve normal vital signs  2 neurologic exams  Confirmatory tests

If I donate my organs, then my body will be mutilated and treated badly. I am scared they will take everything, not just what I want to donate.

 Donated organs are removed just like any other operative procedure.  The body is not disfigured and normal funeral arrangements can be made.  You may specify the organs you want donated and your wishes will be followed.

When I get a kidney transplant they will take out my old kidneys and I will have a horrible scar.

Kidney transplant is a heterotopic transplant. The transplanted organ does not go in the position of the original organ. Liver, Heart and Lung transplant are orthotopic transplants. The diseased organ must be taken out to place the transplant.

Kidney transplantation will cure my kidney disease.

Kidney transplantation is a treatment option for End Stage Renal Disease (ESRD), or kidney failure NOT A CURE!!!!

I have to be on dialysis to get a kidney transplant and once I get on the list I will get transplanted

 The preference is for a patient to receive a transplant before dialysis.  There are allocation rules that all programs must follow.

 Local (donor service area), then Regional, then National  Transplant Candidates prioritized by time waiting  Priority points for sensitized patients, pediatric and prior kidney donors  Regional Variances to National Allocation Scheme

Living Kidney Donors Will have to pay for the donation Will have to take medication Will have a long hospital stay and pain Will not be able to exercise again Will have to follow a special diet Will not be able to drink alcohol Will not be able to get pregnant Will not be able to have sex

Open Left Nephrectomy Scar

Laparoscopic Hand Assisted Kidney Donation

 Cost of organ removal and hospital care go to the transplant recipient.

 No medication needed.  Will receive pain medication for the immediate post op period

 No dietary restrictions  May consume alcohol in moderation.  May return to regular activities and exercise at approximately 4-6 weeks following surgery

 May engage in sexual activity when they feel well enough to do so.  Wait 3 -6 months after donation  The body needs time adjust to living with one kidney

 Kidney Transplant is routinely successful  Cost efficient  Improves Patient Survival and Quality of life  Limited Only by Donor Availability

Matthew Brown, MD Hartford Hospital Transplant Program

 Liver: Meld Score, minimize mortality on wait list  Lung Allocation Score: minimize wait list mortality and post transplant one year mortality  Kidneys: allocate based on time waiting, with priority for pediatrics, sensitized patients and prior donors. Goal of fairness.

 Local (donor service area), then Regional, then National  Transplant Candidates prioritized by time waiting  Priority points for sensitized patients, pediatric and prior kidney donors  Regional Variances to National Allocation Scheme

Current Rank Ordering of Listed Transplant Candidates 1 point per year since listing (waiting time), 4 points if CPRA >=80% 4 points if candidate is a prior living donor (very few candidates are prior living organ donors) 1 point for 1 DR HLA mismatch, 2 points for 0 DR HLA mismatch

 High Discard Rates, particularly from older donors  Variable access to transplant by region and blood group  Kidneys with long longevity allocated to patients with shorter potential. (unrealized graft years)  Kidneys with short longevity (high KDPI) allocated to patients with long expected survival. (high re-transplant rate)

NEW KIDNEY ALLOCATION CONCEPT

 Existing System: Standard criteria donor vs Extended Criteria donor. 4 factors give Binary score (yes/no)  Newer Score: KDPI, Kidney Donor Profile Index. 10 donor factors lead to continuous score

KDPI: Donor Characteristics age race/ethnicity hypertension diabetes creatinine cerebrovascular cause of death height weight donor after cardiac death hepatitis c

KDPI, Risk of Renal Graft Failure

Kidney Allocation Current System  Kidneys meeting expanded criteria donor (ECD) thresholds are allocated first to candidates willing to accept these kidneys.  Kidneys not meeting ECD thresholds are allocated to all candidates on the waiting list as standard criteria donor (SCD) kidneys. Proposed System  Kidneys with a KDPI >20% are allocated to all candidates.  Kidneys with a Donor Profile Index (KDPI) score <=20% are allocated first to candidates with the longest 20% estimated post- transplant survival (EPTS).  Very high KDPI kidneys to be offered to wider geographic area

candidate age length of time on dialysis any prior organ transplant diabetes status

Estimated Life Span, Post Transplant

 Use KDPI instead of “extended criteria donor”  Allocate the best Kidney Grafts to the patients with the highest EPTS  Standardize the “time waiting” calculation starting at ESRD development rather than time of listing  Eliminate regional variances to the allocation policy  Eliminate the “pay back” system  Allocate certain blood group A subtypes to group B recipients  Broader geographic offering of high KDPI score kidneys

 Advantages  Increase Life years gained  Reduce retransplant rate  Increase utiilization of marginal kidney grafts  Remove geographic variances  Disadvantages  Possible reduction in kidneys allocated to Diabetic patients  Possible reduction in Kidneys allocated to the elderly