1. Kidney and Kidney/Pancreas Transplantation in a Year
Reem Daloul, MD
Assistant Professor of Medicine
The Ohio State University

2. Transplantation Landscape in a Glance

3. Kidney Transplant Trends
The transplant numbers have been staggering despite growing waitlist for the last decade or so until 2014 when transplants finally started to see some increased growth
Also, for the first time since transplant started, the numbers of patients on the deceased wait list, both active and inactive, has declined
*OPTN/SRTR 2016 report

4. Transplant by Donor Type
Break Down The Numbers
Waiting List
Kidney
Liver
Pancreas
Kidney/Panc
Heart
Lung
Intestine
Candidate
94,954
13,773
876
1,628
3,951
1,465
254
Transplant by Donor Type
2017
2016
2015
2014
2013
2012
2011
All Donor
34,770
33,610
30,974
29,539
28,955
28,053
28,540
Deceased
28,588
27,630
24,985
23,720
22,967
22,187
22,518
Living
6,182
5,980
5,989
5,819
5,988
5,866
6,022

5. Transplant is Affected by the Opioid Crisis
*OPTN/SRTR 2017 report

6. National Average Waitlist Time
The average waiting time on the deceased list continues to be very variable between different donation service areas.
This is mostly dependent on the OPO function. While the composition of the population in a specific DSA could affect rate of donation, the major drive for more or less eppears to be related to the OPO activity and how active/aggressive the OPO is in trying to obtain consent
percentage of transplant within fiver years of listing per DSA

7. New KAS Allocation System
In 2014, a new kidney transplant (KAS) allocation system was implemented
Improve donor-recipient matching to improve graft longevity
Increase access to disadvantage groups (highly sensitized, B blood group, minorities)
Incorporated two new concepts;
Kidney donor profile index (KDPI), scores from 0-100%
Estimated post transplant survival (EPTS), scores 0-100%
Changes to the points system
Waiting time starts from dialysis date not listing date
Priority to patient with cPRA >89%
Allowed transplantation of A2 organs into B blood type

8. Short-Term Effects of new KAS; Bolus Effect
*D. E. Stewart et al. AJT 2016

9. Short-Term Effects of new KAS, Racial Disparity
After implementation of KAS, there has been increased number of tx among Hispanic and black. This is most likel due to increased credit given for time on dialysis before listing. However, disparity persists, especially in terms of living donation.
*OPTN/SRTR 2017 report

10. Treatments Trends *OPTN/SRTR 2017 report
Almost 75% of program use T-cell depletion
mTORI use has dropped to about 4%
Over 71% of program uses chronic prednisone
*OPTN/SRTR 2017 report

11. What about Belatacept? No available date regarding trends of use yet
Belatacept has been in shortage up until August of 2018
Its use continues to be explored in other organs including lung, heart, and combined K/P

12. Kidney Transplants Outcomes
51.6%
34.2%
Risk for graft failure in Deceased donor recipient
Risk for graft failure in living donor recipient
*OPTN/SRTR 2017 report

13. ABMR As a Major Reason For Long Term Graft Failure
*Sellares J. Am J Transplant 2012

14. Exploring New Venues!

15. Using HCV+ Donors!

16. Pancreas Transplant

17. Pancreas Transplant Trends
Adults on the waiting list Dec 31 each year
Pancreas transplantation rate has been steadily declining over the past decades and this is also reflected by less people on the wait list
*OPTN/SRTR 2017 report

18. New Transplant Allocation System 2014
New allocation system:
Allowed Type-II DM with BMI <30
Joined all types of pancreas transplant candidates in one list and treated them equally
Pancreas Transplant
Increase in Pancreas transplant is largely driven by increase in SKP transplant

19. Incentives for SKP Transplant
Wait time is much shorter for SKP compared to kidney alone
KDPI is usually lower reflecting high quality of donors whose pancreas is suitable for transplantation
Pancreas transplant program are becoming more aggressive offering SKP to older patients and patients with higher BMI

20. Immunosuppression Trends
*OPTN/SRTR 2017 report

21. Outcomes in Pancreas Transplant
Graft failure within 90 days of transplant
Acute rejection within first year post Transplant
Outcomes reporting for pancreas transplant is not as straight forward as it is for kidney transplant. Mainly because up until 2017, there has been no concise definition of graft failure. So the definition varied from one center to the other. This makes it difficult to define long term outcomes but we can still look at some short terms outcomes such as patient survival and acute rejection rate
90 days graft survival over the last 5 years or so has been relatively stable around 8% form most kind of pancreas transplant. This in part reflect improved surgical technique and comfort with pancreas transplantation and probably better organ selection
Similarly, risk for acute rejection in the first year have significantly improved
*OPTN/SRTR 2017 report

22. Outcomes in Pancreas Transplant
Patient death at 1 year
Patient death at 5 years
Patient death at 10 years
*OPTN/SRTR 2017 report

23. Outcomes in Pancreas Transplantation
Outcomes in pancreas transplant is dependent on center volume
*T. Alhamad et al. Transplantation 2017

24. Summary Kidney transplant numbers has increased over the last 2 years
This increase is attributed solely to an increase in deceased donor donation
The kidney transplant field continues to explore new sources for organ donation, including donors infected with HIV and HCV viruses
Pancreas transplantation has been overall on the decline for the last 10 years
Simultaneous kidney pancreas transplant has shown some rebound in the last two years
Outcomes of pancreas transplantation continues to improve but appears to be dependent on center volume

25. THANK YOU
Reem Daloul