1 Revising Kidney Paired Donation Pilot Program Priority Points Kidney Transplantation Committee Fall 2015

2 What problem will the proposal solve? OPTN KPD system does not fully consider: Increased difficulty in matching some pairs (i.e. high CPRA and certain blood types) Certain data to identify matches more likely to be accepted Problem 1 Revise optimization algorithm’s priority points to identify matches to optimize the pair pool for “difficult to match” pairs and consider potentially relevant data Solution

3 What problem will the proposal solve? KPD informed consent policies will require programs to inform on remedies for failed exchanges (if one exists) OPTN policy does not provide a remedy for candidates in failed exchanges in the OPTN KPD Problem 2 Award high point value to “orphan candidates” (1,000,000 points) Ensures that NDD chain will end with “orphan candidate” if possible Only applies to candidates “orphaned” in the OPTN KPD Solution

Maintain Base points for all matches (100 pts) Points for prior living donors and pediatric candidates Waiting time Remove Points for same region and same DSA Negative points for “all other antibody specificities” Revise Adopt a sliding scale CPRA Increase points for same hospital matches Reduce points for 0-ABDR mismatches Add Points Categories Candidate and paired donor ABO Previous negative or positive but acceptable crossmatches (with or without desensitization) Orphan candidates How does the proposal address the problem statement? 4

Sensitivity Study Design Re-optimized 136 historical OPTN KPD match runs using 24 scenarios Evaluation # and % of matches by candidate and pair characteristics Match rate Change in total # of matches found Impact of potential changes on equitable access for patients Limitations Focus on # of matches, not transplants Static study Limited ability to evaluate small subpopulations (i.e. living donors) Supporting Evidence 5

 Increased the # of matching opportunities for 99% and 100% CPRA candidates  Prioritizing by pair characteristics increased the # of matching opportunities for hard to match pairs  Blood type O candidates  Candidate’s whose paired donor is non-O Supporting Evidence – Overall Trends 6

 Members participating in KPDPP will need to communicate the changes as a part of informed consent, particularly about the remedy for a failed exchange  Proposal does not require additional data collection  No changes to current routine site surveys  Anticipated Board Date: December 2015  Implementation Date: Pending programming How will members implement this proposal? 7

 Increase the number of transplants  Increase # of matches found  Incentivize transplant hospitals to participate  Use data to improve chance of timely offers to candidates most likely to accept  Improve equity in access to transplants  Addresses increased difficulty in matching certain blood types and CPRA levels  Improves access for candidates in failed exchanges How does this proposal support the OPTN Strategic Plan? 8

Dr. Mark Aeder Committee Chair Regional representative name (RA will complete) Region X Representative address Melinda Woodbury Committee Liaison Questions? 9

Extras 10

If the:Then the match will receive: Candidate is a 0-ABDR mismatch with the potential donor 200 points Candidate has a CPRA greater than or equal to 80% 125 points Candidate is a prior living organ donor150 points Candidate was less than 18 years old at the time the candidate was registered in the OPTN KPD program 100 points Candidate and potential donor are registered for the OPTN KPD program in the same region 25 points Candidate and potential donor are registered for the OPTN KPD program in the same DSA 25 points Transplant hospital that registered both the candidate and potential donor in the OPTN KPD program is the same 25 points Potential donor has at least one of the other antibody specificities reported for the candidate - 5 points Current KPD Priority Points 11 ***All OPTN matches receive 100 base points

If the:Then the match will receive: Candidate is registered for the OPTN KPD program.07 points for each day according to Policy 13.7.F: OPTN KPD Waiting Time Reinstatement Candidate is a 0-ABDR mismatch with the potential donor10 points Transplant hospital that registered both the candidate and potential donor in the OPTN KPD program is the same 75 points Candidate and potential donor had a previous crossmatch that was one of the following: Negative Positive and acceptable with desensitization Positive and acceptable without desensitization 75 points Candidate was less than 18 years old at the time the candidate was registered in the OPTN KPD program 100 points Candidate is a prior living organ donor150 points Candidate ABO is: O 100 points B50 points A25 points AB0 points Paired donor ABO is: O 0 points B100 points A250 points AB500 points 12 Revised Priority Points All OPTN matches will continue to receive 100 base points

If the:Then the match will receive: Candidate CPRA is: points points points points points points points points points points points points points points points points points Candidate is an orphan candidate1,000,000 points 13 Revised Priority Points All OPTN matches will continue to receive 100 base points

Supporting Evidence 14 CPRA Scales CPRA Current Policy Proposed CPRA Sliding Scale

Supporting Evidence 15 *Sum of all candidates across all 136 match runs. Some candidates appeared in multiple match runs. Impact of CPRA Sliding Scale On Matches # Matches Found CPRA# Candidates*% of CandidatesCurrent PolicyCPRA Sliding Scale 0% 7, % 2, % 1, % 1, % 1, % 2, % 1, % 3, % 9, All 32,

Impact of CPRA Sliding Scale on Very Highly Sensitized Match Rates (# matches / # candidates) CPRA# Candidates* % of Candidates Current PolicyCPRA Sliding Scale 0%7, %2.7% 1-49%2, %6.3% 50-79%1, %9.8% 80-89%1, %6.7% 90-94%1, %2.5% 95-97%2, % 98%1, % 99%3, %1.1% 100%9, %0.4% All32, % Supporting Evidence 16 *Sum of all candidates across all 136 match runs. Some candidates appeared in multiple match runs.

Supporting Evidence 17 *Sum of all candidates across all 136 match runs. Some candidates appeared in multiple match runs. Impact of CPRA Sliding Scale on Age Match rates (# matches / # candidates) Candidate Age # Candidates* % of Candidates Current Policy CPRA Sliding Scale %0.8% , % , %2.2% , %2.9% 65+3, %3.1% All32, %

Supporting Evidence 18 *Sum of all candidates across all 136 match runs. Some candidates appeared in multiple match runs. Match Rates (# matches / # candidates) Race/Ethnicity # Candidates* % of Candidates Current Policy CPRA Sliding Scale White21, %2.4% Black5, % Hispanic4, %2.2% Asian1, %6.2% Other %2.3% All32, % Impact of CPRA Sliding Scale on Race/Ethnicity

Supporting Evidence 19 If the:ABO is: Then the match will receive: CandidateO100 points B50 points A25 points AB0 points Paired Donor O0 points B100 points A250 points AB500 points

Supporting Evidence 20 *Sum of all candidates across all 136 match runs. Some candidates appeared in multiple match runs. Impact of Candidate ABO Points # Matches Found Match Rates (# matches / # candidates) Candidate ABO # Candidates* % of Candidates Current Policy (0 points) Candidate ABO Points (0-100 points) Current Policy (0 points) Candidate ABO Points (0-100 points) A5, %4.3% AB %2.4% B5, %4.5% O20, %1.8% All32, %2.7%

Supporting Evidence 21 *Sum of all candidates across all 136 match runs. Some candidates appeared in multiple match runs. Impact of Candidate ABO Points on Race/Ethnicity Match Rates (# matches / # candidates) Race/ Ethnicity # Candidates* % of Candidates Current Policy (0 points) Candidate ABO Points (0-100) White % Black %2.9% Hispanic % Asian % Other % All %2.7%

Supporting Evidence 22 *Sum of all candidates across all 136 match runs. Some candidates appeared in multiple match runs. Impact of Candidate ABO Points on Age Match Rates (# matches / # candidates) Candidate Age # Candidates* % of Candidates Current Policy (0 points) Candidate ABO Points (0-100) %1.4% , % , % , %3.1% 65+3, %2.8% All32, %2.7%

Supporting Evidence 23 *Sum of all candidates across all 136 match runs. Some candidates appeared in multiple match runs. Impact of Paired Donor ABO Points # Matches Found Match Rates (# matches / # candidates) Paired Donor ABO # Candidates* % of Candidates Current Policy (0 points) Paired Donor ABO (0-500 points) Current Policy (0 points) Paired Donor ABO (0-500 points) A 16, %1.80% AB 1, %0.41% B 5, %3.59% O 10, %3.32% All 34, %2.51%

Supporting Evidence 24 *Sum of all candidates across all 136 match runs. Some candidates appeared in multiple match runs. Impact of Paired Donor ABO Points on Race/Ethnicity Match Rates (# matches / # candidates) Race/Ethnicity# Candidates* % of Candidates Current Policy (0 points) Paired Donor ABO (0-500 points) White %2.6% Black % Hispanic %1.9% Asian %6.3% Other % All %2.7%

Supporting Evidence 25 *Sum of all candidates across all 136 match runs. Some candidates appeared in multiple match runs. Impact of Paired Donor ABO Points on Age Match Rates (# matches / # candidates) Candidate Age # Candidates* % of Candidates Current Policy (0 points) Paired Donor ABO (0-500 points) % , %2.3% , %2.4% , % 65+3, % All32, %2.7%