1. The Deceased Donor Kidney Allocation System

2. 123,208 organ tx candidates are on the waiting list
As of February 15…
123,208 organ tx candidates are on the waiting list
101,603 are waiting for a kidney tx

3. Overall Changes to Allocation System
Waiting time calculation
Pre-registration dialysis time added
Candidate classification
Estimated Post Transplant Survival Score (EPTS)
Kidney donor classification
Replace SCD/ECD with Kidney Donor Profile Index (KDPI)
Candidates are eligible to receive waiting points for administration of ESRD dialysis that occurred prior to their being listed on the waitlist.
All adult candidates have an Estimated Post Transplant Survival score, or EPTS. This score was designed to promote better longevity matching between donor and recipient in order to utilize the maximum amount of graft years post-transplant.
Standard Criteria Donors (SCD) and Expanded Criteria Donors (ECD) are being replaced with a more refined metric known as the Kidney Donor Profile Index or KDPI.

4. Recent Allocation Component Changes
Priority for sensitized candidates
Calculated panel reactive antibody (CPRA) sliding scale, regional/national sharing for CPRA greater than 98%
Pediatric kidney allocation
KDPI priority
Blood type eligibility
A2 and A2B to B compatible
Highly sensitized candidates get priority for kidneys through additional sharing and a sliding scale points system for calculated panel reactive antibody or CPRA scores.
Greater access to deceased donor kidneys for blood type B candidates who can safely accept a kidney from an A2 or A2B blood type donor; and
For pediatric candidates, priority will be based on the donor’s KDPI instead of the donor’s age.

5. Candidate Priority Kidney candidate priority
Priority points
Match classification (position on the match run)

6. Sequence A Sequence B Sequence C Sequence D KDPI <=20%
KDPI >20% but <35%
Sequence C
KDPI >=35% but <=85%
Sequence D
KDPI>85%
Highly Sensitized
0-ABDRmm (top 20% EPTS)
Prior living donor
Local pediatrics
Local top 20% EPTS
0-ABDRmm (all)
Local (all)
Regional pediatrics
Regional (top 20%)
Regional (all)
National pediatrics
National (top 20%)
National (all)
0-ABDRmm
Local adults
Regional adults
National adults
Local
Regional
National
Local + Regional
These are the four allocation sequences for kidney allocation. The four sequences are based on the donor’s KDPI score.

7. Waiting Time Points Priority
Dialysis start date
Date after registration that eGFR is at or below 20 mL/mn
1 point for each year on the waiting list
Tiebreaker is date of registration
Peds begin accruing time at listing, receive credit for any pre-listing dialysis time
*Peds begin accruing waiting time at listing regardless of clinical factors

8. Waiting Time Qualifiers
Dialysis
Determined by listing center
Waittime may start prior to listing
Multiple centers may have equal waittime points
Acceptable methods of documentation
2728, dialysis center letter, physician note
GFR/Cr Clearance
Waittime can only start at or after candidate is listed
Only one center can have longest waittime points
Laboratory

9. Multiple Listing with Dialysis as the Waittime Qualifer
Multiple DSAs listing
Access to different local donor pool
Completing with different candidates
Multiple local listings
Alternate clinical interventions available
Different acceptance rates and parameters

10. Estimated Post Transplant Survival
Current diagnosis of diabetes
Time on dialysis
Any prior solid organ transplant
Candidate’s age
All adult candidates receive an Estimated Post-Transplant Survival (or EPTS) score. The EPTS score is a numerical measure used in the new kidney allocation system to identify those candidates expected to live the longest after a kidney transplant.
Let’s review the factors included in the EPTS formula:
candidate’s age
time on dialysis
whether or not the candidate has a current diagnosis of diabetes
whether the candidate has had any prior solid organ transplant
EPTS scores range from 0% to 100%.
EPTS score range 0%-100%

11. EPTS Match Classification Priority
EPTS score used to identify two groups of patients*
Those with scores of 0-20%
Those with scores of %
*The top 20% EPTS is calculated based on a national pool of candidates from a certain time period.
The EPTS score will be calculated based on the national pool of candidates, but it will only be used to identify two broad groups of candidates in that pool:
those with scores of 20% or less, and
those with scores exceeding 20%.
(Note: EPTS only identifies these two groups, but not rank order of candidates on the match.)
Candidates with a lower EPTS score are expected to experience more years of graft function from high-longevity kidneys compared to candidates with higher EPTS scores.
In general, candidates with lower EPTS scores tend to be of a younger age.
Analysis has revealed that candidates in their mid-50s can still have EPTS scores in the Top 20%.
Though candidates with diabetes tend to have higher EPTS scores, the same analysis showed that some younger diabetics have EPTS scores of 20% or less.
Candidates who have had a prior solid organ transplant, as well as those having spent many years on dialysis, tend to have higher EPTS scores.

12. Kidney Donor Profile Index
KDPI based on:
Donor age
Height
Weight
Ethnicity
History of hypertension
History of diabetes
Cause of death
Serum creatinine
Hepatitis C virus status
Donation after circulatory death
Kidney Donor Profile Index (KDPI)
KDPI is a numerical measure that combines ten dimensions of information about a kidney donor, including clinical parameters and demographics, to express the relative longevity of that donor kidney compared to the entire deceased kidney donor pool.
KDPI is calculated by using the donor variables of:
Age
Height
Weight
Ethnicity
History of hypertension
History of diabetes
Cause of death
Serum creatinine
Hepatitis C status
Whether the donor donated organ after circulatory death
These factors are used to calculate a percentage score that is associated with how long a kidney offered is likely to function after transplantation based on a historical cohort of similar donated kidneys. The lower the KDPI the greater the likelihood that the kidney will have a longer time of function in the recipient.
KDPI scores range from 0-100%
Lower KDPI is associated with better longevity

13. Using the KDPI to Predict Graft Survival

14. EPTS & KDPI in the New System
Longevity Matching
EPTS
0-20%
KDPI
The intent of longevity matching is to ensure that kidneys expected to function the longest are most often transplanted into those candidates expected to live the longest, thereby realizing the greatest benefit from kidney transplantation.
Thus, the EPTS will be used in tandem with the KDPI to introduce the concept of longevity matching into the new allocation system. The EPTS score will only be used in kidney allocation when the donor has a KDPI of 0-20%. In other words, the EPTS will be used to prioritize candidates in only 20% of kidney allocations, while for 80% of allocations EPTS will not be used at all.

15. Candidate Points Report

16. National 20% EPTS OHOU Blood Type O candidates
48 candidates that fall within the 20%

17. Sequence A Sequence B Sequence C Sequence D KDPI <=20%
KDPI >20% but <35%
Sequence C
KDPI >=35% but <=85%
Sequence D
KDPI>85%
Highly Sensitized
0-ABDRmm (top 20% EPTS)
Prior living donor
Local pediatrics
Local top 20% EPTS
0-ABDRmm (all)
Local (all)
Regional pediatrics
Regional (top 20%)
Regional (all)
National pediatrics
National (top 20%)
National (all)
0-ABDRmm
Local adults
Regional adults
National adults
Local
Regional
National
Local + Regional
These are the four allocation sequences for kidney allocation. The four sequences are based on the donor’s KDPI score.

18. Sequence A KDPI <= 20% Highly Sensitized (CPRA 98+)
0-ABDRmm (0-20% EPTS)
Prior living donor
Local pediatrics
Local (0-20% EPTS)
0-ABDRmm (21-100% EPTS)
Local (21-100% EPTS)
Regional Pediatrics
Regional (0-20% EPTS)
Regional (21-100% EPTS)
National Pediatrics
National (0-20% EPTS)
National (21-100% EPTS)
Candidates with EPTS scores of 0-20% will be prioritized ahead of candidates with lower scores, but only for the highest longevity kidneys, which are those that have a KDPI of less than or equal to 20%.
What you see on this slide shows the allocation sequence of KDPI 20% or less kidneys. You can see that patients with an EPTS of 0-20% will receive priority for zero mismatches[animation], local offers[animation], as well as regional [animation] and national [animation] offers.
It is also important to note that allocation proceeds first to local patients with EPTS of 0-20%, followed by local patients with EPTS exceeding 20%, before offers are made regionally or nationally.

19. CPRA score Based on unacceptable antigens listed for the candidate
Used to calculate how many donors will be incompatible with the candidate
Ranges from 0-100%
Immune system sensitivity is assessed by the CPRA score.

20. CPRA Priority Points CPRA Sliding Scale (Allocation Points) 20 18 16
0.08
0.21
0.34
0.48
0.81
1.09
1.58
2.46
4.05
6.71
10.82
12.17
17.30 2 4 6 8 10 12 14 16 18 20 30 40 50 60 70 80 90
100
Points
CPRA Sliding Scale (Allocation Points)
(CPRA<98%)
CPRA points are assigned based on a CPRA sliding scale, beginning at a CPRA score of 20%.
Candidates with a CPRA from 80 to 84 receive about 2.5 points, while candidates with CPRA of 85 to 89 will receive just over 4 points.
Candidates with CPRA’s in the high 90’s receive substantially more points: for example, candidates with CPRA scores of 99 and 100% will receive 50 and 202 points, respectively.
CPRA
CPRA

21. CPRA Match Classification Priority
Sequence A
KDPI <=20%
Sequence B
KDPI >20% but <35%
Sequence C
KDPI >=35% but <=85%
Sequence D
KDPI>85%
Highly Sensitized
0-ABDRmm (top 20% EPTS)
Prior living donor
Local pediatrics
Local top 20% EPTS
0-ABDRmm (all)
Local (all)
Regional pediatrics
Regional (top 20%)
Regional (all)
National pediatrics
National (top 20%)
National (all)
0-ABDRmm
Local adults
Regional adults
National adults
Local
Regional
National
Local + Regional
CPRA greater than 98%
In order to get priority, lab director and physician/surgeon must sign written approval of unacceptable antigens and this must be reported in UNet.

22. Pediatric Status Points
Aged 0-10 at the time of the match run and 0-ABDR mismatch with donor = 4 points
Aged 0-10 at the time of the match run and the donor’s KDPI is less than 35% = 1 point
Aged at time of the match run and a 0-ABDR mismatch with donor = 3 points

23. Pediatric Match Classification Priority
Sequence A
KDPI <=20%
Sequence B
KDPI >20% but <35%
Sequence C
KDPI >=35% but <=85%
Sequence D
KDPI>85%
Highly Sensitized
0-ABDRmm (top 20% EPTS)
Prior living donor
Local pediatrics
Local top 20% EPTS
0-ABDRmm (all)
Local (all)
Regional pediatrics
Regional (top 20%)
Regional (all)
National pediatrics
National (top 20%)
National (all)
0-ABDRmm
Local adults
Regional peds
Regional adults
National adults
Local
Regional
National
Local + Regional
*Pediatric match classification priority is based on age at the time of registration (not time of the match run)

24. Prior Living Organ Donors
4 points with every registration
Prior living organ donors receive 4 points with every registration (for second or additional transplants).

25. Sequence A Sequence B Sequence C Sequence D KDPI <=20%
KDPI >20% but <35%
Sequence C
KDPI >=35% but <=85%
Sequence D
KDPI>85%
Highly Sensitized
0-ABDRmm (top 20% EPTS)
Prior living donor
Local pediatrics
Local top 20% EPTS
0-ABDRmm (all)
Local (all)
Regional pediatrics
Regional (top 20%)
Regional (all)
National pediatrics
National (top 20%)
National (all)
0-ABDRmm
Local adults
Regional adults
National adults
Local
Regional
National
Local + Regional
These are the four allocation sequences for kidney allocation. The four sequences are based on the donor’s KDPI score.

26. HLA-DR matching priority points
A zero HLA-DR mismatch with the donor = 2 points
A single HLA-DR mismatch with the donor = 1 point

27. HLA Match Classification Priority
Sequence A
KDPI <=20%
Sequence B
KDPI >20% but <35%
Sequence C
KDPI >=35% but <=85%
Sequence D
KDPI>85%
Highly Sensitized
0-ABDRmm (top 20% EPTS)
Prior living donor
Local pediatrics
Local top 20% EPTS
0-ABDRmm (all)
Local (all)
Regional pediatrics
Regional (top 20%)
Regional (all)
National pediatrics
National (top 20%)
National (all)
0-ABDRmm
Local adults
Regional adults
National adults
Local
Regional
National
Local + Regional

28. Rank-ordering of Candidates within each Match Classification
Total points determined by:
Waiting time
CPRA sliding scale
HLA-DR matching
Pediatric status
Prior living donor status
Tiebreaker = date of registration
Within each of the allocation categories discussed, these two EPTS groups, will be rank-ordered on the match by total allocation points.
Remember that allocation points are determined by:
time on dialysis, or time after meeting eGFR (glomerular filtration rate) or CrCl (creatinine clearance) criteria,
the calculated PRA or CPRA sliding scale,
HLA-DR matching,
pediatric status, and
prior living donor status.
If a tie-breaker is needed, the date of registration will be used.

29. Transplant Pro Resources

30. Example of Resources

31. Chrystal Graybill chrystal.graybill@unos.org 804-782-4631
Questions?
Chrystal Graybill