1. Philosophy of Organ Allocation
Rachel Hilton
Guy’s & St Thomas’ NHS Foundation Trust

2. Terms of reference
To determine the criteria for listing for a kidney transplant;
To evaluate the key principles of allocation;
To consider whether priorities should differ at the extremes of age;
To determine how best to maximise the benefit of each donor - recipient combination, to include consideration of measures of organ quality;
To determine the contribution of time spent on the waiting list to allocation priority.

3. Members Rachel Hilton, nephrologist, London (chair)
Alison Brown, nephrologist, Newcastle
Tim Brown, transplant surgeon, Belfast
Marc Clancy, transplant surgeon, Glasgow
Antonia Cronin, nephrologist, London
Heather Draper, ethicist, Birmingham
Chris Dudley, nephrologist, Bristol
Victoria Fox, lay member
Nick Inston, transplant surgeon, Birmingham
Mark Korad, patient representative
Bernadette Li, health economist, London
Rommel Ravanan, nephrologist, Bristol
Mandy Venters, patient representative
Chris Watson, transplant surgeon, Cambridge
Diana Wu, research fellow, Edinburgh

4. Work schedule Face to face meeting 2nd October 2015 Teleconferences
10th December 2015
19th January 2016

5. Access to the kidney transplant waiting pool should be offered to patients who, in the opinion of their lead clinician, or, where there is uncertainty, the multidisciplinary team, have a greater than 50% likelihood of surviving at least 5 years from the time of transplantation
Access to waiting list determined by an estimated post-transplant survival threshold is a recurring theme in other kidney allocation schemes around the world.
The main argument is that setting such a target means that all transplant units will be using the same benchmark for assessing patients
In Australia and New Zealand listing is restricted to patients with a 80% likelihood of surviving for at least 5 years after transplantation – which we thought was too stringent and that many currently listed UK patients would not meet this criterion.
In line with other European countries the UK has adopted a greater than 50% likelihood of 5-year survival as the threshold for listing.
We acknowledge that 5-year survival is often difficult to predict, apart from in certain situations such as malignancy and heart failure which would themselves would preclude listing.
Survival prediction should ideally result from the shared opinion of the multidisciplinary team, the clinician and the patient.
While perhaps desirable for all, discussion by the regional multidisciplinary team should be mandatory for patients where there is uncertainty or concern on the part of the lead clinician.
 ATTOM may help define such “grey area” patients, likely to be based on similar criteria to those that inform the EuroSCORE cardiac risk calculator.

6. Lower risk kidneys (assessed by UKKDRI) should be offered to potential Recipients with the longest predicted post-transplant survival (estimated using EPTS)
We acknowledged the attraction of the new US kidney allocation scheme, which attempts to match the “right kidney to the right recipient” thus minimising mismatch between recipient and graft survival
We thought that this would increase the utility of organ offering by hopefully increasing the longevity of these higher quality organs in recipients with longer life expectancy, thus minimising loss of potential graft function
We considered whether this might apply to all organ offers or only to the highest scoring 20% as in the new US system
In the end we favoured using the UKKDRI and EPTS calculators to rank organ and recipient “quality” along a continuous “sliding scale” resulting in a general principle that lower risk organs should be offered to recipients with higher predicted survival.

7. Children (individuals aged up to the age of 16) should have a higher priority than adults (individuals aged 16 and older)
Compared with dialysis, kidney transplantation confers significant survival and quality of life benefits for children with kidney failure, while offering time-sensitive opportunities for growth and psychosocial development.
There is a strong public perception that children should be advantaged, and what we discussed fairly vigorously was the appropriate age threshold.
The current definition (an individual under the age of 18) is at odds with the definition for liver transplant candidates, heart transplant candidates, and indeed for the definition of a child in the NHS, which is usually an individual under the age of 16.
There was no clear consensus, but a preference for defining transition to adulthood at age 16, rather than 18, accepting that use of the EPTS calculator would ensure that younger recipients would retain priority for the highest quality kidneys.
 This would be in line with Eurotransplant offering criteria.
We acknowledge that younger recipients would be likely to benefit from better HLA matched kidneys.

8. Highly Sensitised Patients (those with cRF of greater than 85%) should retain priority
Highly Sensitised patients are difficult to transplant so should retain priority
We also discussed other patients who may benefit from prioritization, such as the clinically urgent, in other words those patients at high risk of access failure.
We thought that this would be difficult to define and that such a policy may indirectly reward centres with inadequate vascular access programmes.

9. Waiting time points should accrue from the start date of dialysis, with no additional points for pre-emptively listed patients
While not wishing waiting time to be the primary driver of organ allocation, we recognise that waiting time is important and that waiting time points should accrue from the start date of dialysis.
The main discussion was around how to manage pre-emptively listed patients.
One suggestion was to cap additional waiting time points at 180 days so as to discourage gaming the system by very early listing.
The majority view, which was strongly held, was that no additional waiting time points should be accrued by pre-emptively listed patients and that access to the waiting list was a sufficient incentive in itself.

10. Thank you to all members of the working group
TRANSPLANT WAITING LIST
Acknowledge all members of working group