1. Thoracic Organ Transplantation Committee
Spring 2015
Hi Everyone, my name is ___________________________ and I’m the Region # Rep for the Thoracic Committee. I’m going to provide you all with a quick update on the projects the Thoracic Committee is working on.

2. Recent Public Comment Proposals
Collect Extracorporeal Membrane Oxygenation (ECMO) Data Upon Waitlist Removal for Lung Candidates
Feedback very favorable
Committee considering suggestions from ISHLT and AST
Expected Board review: June 2015
The Thoracic Committee distributed a proposal to collect ECMO data upon waitlist removal for lung candidates for public comment in the Fall of The feedback from regions, committees and the public was largely favorable. ISHLT and AST suggested capturing even more granular data than the committee originally proposed. During the next few months, the Lung Subcommittee will review the suggestions and make a final recommendation to the Thoracic Committee regarding the data that should be collected. We anticipate sending this proposal to the Board for review in June 2015.

3. Clarification of LAS of 50 or Higher
Implementation: February 1, 2015
Clarification for reporting additional data for LAS of 50 or higher candidates
Policy requirements have not changed
Modifications:
Updated tips for complying with this policy
Education Opportunities:
Policy 10.1.G: Reporting Additional Data for Candidates with an LAS of 50 or Higher went into effect on February 1, However, transplant programs have expressed difficulty with understanding and complying with the policy, and UNOS’ Member Quality staff has expressed difficulty with monitoring the policy. The Thoracic Committee worked with these groups to clarify the language in the policy so that it can be monitored. The clarified language went into effect on February 1st this year. The requirements in the policy haven’t changed: if a candidate’s LAS becomes 50 or higher, the transplant program must report values for assisted ventilation, supplemental oxygen and PCO2 every 14 days, as long as the candidate’s LAS remains 50 or higher. If the transplant program is unable to obtain a PCO2 value for the candidate in the 14 day period, it does not have to report the value.
UNOS staff is working to create materials to help transplant programs better understand this policy and to provide tips to help comply with the policy. These tips should be ready in March 2015, and will be posted on the OPTN website and Transplant Pro.

4. LAS Modification Implementation
Implementation : February 19, 2015
Bilirubin collected and factored into LAS calculation
Some variables already collected now factored into LAS calculation (cardiac index, CVP)
Serum creatinine and bilirubin collected serially, like PCO2
New lung diagnoses added
Lung diagnosis exception button now available for candidates less than 11 years, 9 months
Modifications:
Content webinar on January 20, 2015
Systems training on February 12, 2015
LAS Toolkit:
Education Opportunities:
Modifications to the lung allocation score (LAS) will be implemented on February 19. The implementation includes many changes that the Board approved over the last few years. The baseline waiting list mortality and post-transplant survival probabilities have been updated to reflect a more current candidate cohort. The changes that will be most noticeable for those of you who interact with the system on a regular basis are the new and modified data elements that will factor into the calculation. Cardiac index and CVP are already collected in the system, and they will now be factored into the candidate’s LAS. Total bilirubin is a new element that will now be collected and factored into the LAS. Just as PCO2 is collected on a serial basis to allow for the LAS calculation to determine if there has been a change in PCO2 that should impact a candidate’s score, serum creatinine and bilirubin will also be collected serially, and the LAS calculation will also look for threshold change in these data to determine if the candidate’s score should be impacted.
There have also been a number of lung diagnoses added to the dropdown list in the system in Diagnosis Groups B and D. The system has also been re-designed to permit transplant programs to submit an exception request to the Lung Review Board if a candidate’s diagnosis is not included on the diagnosis list. This option has always been available for candidates older than 11 years, 9 months, but the option has now been made available to candidates of all ages.
UNOS hosted a content webinar on January 20 to review the significant policy changes that will be implemented on February 19. The webinar is recorded, so if you’d like to hear it you can visit the LAS toolkit on the OPTN website. The link to the toolkit on the OPTN website is
UNOS also hosted a systems training on February 12 to demonstrate some new and modified functionality in UNet as a result of these policy changes. This training was also recorded and will be available for any of you who have access to UNet. Additional materials regarding the LAS changes, including updated patient and professional brochures, will be posted online on Transplant Pro and the OPTN website to help you during this transition.

5. Ongoing Committee Initiatives
Adult Heart Allocation Modification
3 additional medical urgency tiers
Debating whether/how to prioritize sensitized candidates
Considering geographic sharing strategies
Heart-lung allocation policy
Pediatric Lung Allocation Policy Modification
ABO incompatible lung transplants for young pediatric candidates
Broader sharing of child and adolescent donor lungs
Debating prioritization of candidates less than 12 for adolescent donor lung offers
We have been working for a long time on refining the adult heart allocation system to improve waiting list mortality for adult heart candidates. The current medical urgency tiers – which are status 1A, status 1B, and status 2 - do not effectively distinguish candidates based on true medical urgency. We worked for a very long time to organize candidates into even more tiers to better address medical urgency. The Committee created 6 active tiers (and 1 inactive tier) for adult heart candidates. We recently received the results of modeling performed by the SRTR to see how candidates would be affected if we were to implement the new tiers, and we are continuing to analyze the results to see whether we would like to submit follow-up requests.
We have also had many debates about whether and how to prioritize sensitized candidates within the new allocation scheme, and we have considered a number of options including assigning sensitized candidates more waiting time days, and allowing sensitized candidates access to a larger pool of donors through a broader sharing scheme. We have also considered putting this issue aside, and simply collecting more data so we can better understand how to design the system to benefit sensitized candidates in the future. These are still ongoing discussions and we haven’t yet reached a decision. We are also going to consider whether the current geographic sharing scheme is adequate, or whether we should make changes to the way in which hearts are allocated by zone. Finally, we hope to include a change to heart-lung allocation policy to make the policy more clear and equitable. Though we released a guidance document in December 2014 to help OPOs comply with the current heart-lung policy, we believe the policy itself needs improvement. We plan to have a proposal ready for the Fall 2015 public comment cycle.
We have also continued discussing pediatric lung allocation policy. Literature and experience in other countries lead us to believe that permitting ABO incompatible transplants to occur in the US for very young pediatric lung candidates would be safe, and would potentially increase the number of organs recovered but not transplanted. There are very few pediatric lung transplant programs in the US, but most of them have expressed interest in performing these transplants if policy permits. We plan on modeling the ABOi lung policy after the ABOi heart policy, which already permits pediatric heart candidates under 2 to be eligible for ABOi heart transplants.
The Committee is also considering sharing child and adolescent donor lungs more broadly among lung candidates under 18. We have reviewed modeling performed by the SRTR and believe that more lung candidates under 18 will benefit from broader sharing, without impacting the transplant rates for adult candidates. The Committee is also debating whether to prioritize pediatric candidates for offers from child and adolescent donors. Like the adult heart allocation policy, we hope to have these proposals packaged together and ready for the Fall 2015 public comment cycle.

6. Questions? Joe Rogers, MD Committee Chair joseph.rogers@duke.edu
Regional Rep name (RA will complete) Region X Representative address
Liz Robbins Callahan Committee Liaison