1. MELD and UNOS James Trotter, MD Baylor University Medical Center Dallas, Texas

2. U.S. liver transplant candidates

3. Liver transplants by year

4. listed transplants

5. Age of newly listed patients %

6. Newly listed patients > 65 y %

7. Newly listed patients MELD > 35 n

8. Percent liver-kidney transplants year advanced age diabetes MELD score 3.8[ln bili] + 11.2[ln INR] + 9.6[ln Cr] + 6.4

9. Removed from list for death

10. Removed from list died on list removed, too sick

11. % died on list+too sick to transplant

12. MELD score 10(0.957ln(Cr) + 0.378ln(bilirubin) + 1.12ln(INR) + 0.643) Wiesner et al. Gastro, 2003

14. high priority for waiting time list patients early in disease list fills with non-sick pts transplant of non-sick pts MELD-based liver allocation sicker pts die waiting changes in 2002

15. high priority for sickness list sicker patients list fills with sick pts transplant of very sick pts many delisted as too sick to transplant long rehab poor fxnality reform is needed current

16. Regional sharing – Share 35

18. Region 4 OKC HOU DFW SAT

19. Region 4 – prior sharing system OKC HOU DFW SAT Under old system, liver procured locally offered to highest MELD local pt, then to region.

20. Region 4 – current regional sharing OKC HOU DFW SAT Under new system, liver procured locally offered to MELD > 35 local pt, then to region MELD > 35.

21. Regional sharing of organs ProsCons - equalize transplant- longer cold time MELD and death rate- more distance traveled - more equitable organ- worse outcomes? allocation- local donation impact - doesn’t “go far enough” - small center impact

31. Liver redistricting – new proposal “if some is good, more is better” wider regional sharing in the US fulfills “Final Rule” – access to donors not limited by geographys normalizes access/waitlist mortality supported by: NYC, BOS, SFO, LAX

32. Liver redistricting – new proposal

33. Liver redistricting - concerns long-travel times (logistics/cost) penalizes good DSA’s, rewards laggards effects of share-35 not fully assessed worsen outcomes not supported by: organ-rich, low-MELD regions: MO, KS, SC, TN, TX

34. Liver redistricting - proposal 110/12,000 = 0.9 % lives saved per year 58 DSA’s in US x 2 livers per year = 116 lives saved

39. Liver redistricting - summary at Chicago meeting 80 % opposed tabled for now Spring 2015 conference to reconsider

42. ALLOCATION OF LIVERS BASED ON THE “SHARE 35” POLICY HAS NO IMPACT ON WAITING LIST MORTALITY AND WORSENS ORGAN UTILIZATION IN UNOS REGION 4 James F. Trotter Baylor University Medical Center

43. Background – Share 35 allocation designed to "decrease wait list deaths and minimize distance traveled" of donor organs its impact has not been reported outcomes of liver transplant candidates and recipients before/after "Share 35" policy in the UNOS Region 4 (Oklahoma and Texas)

44. Region 4 – current regional sharing OKC HOU DFW SAT

45. Distance between region 4 cities OK City – San Antonio422 Amarillo – Houston533 El Paso – DFW 573 New York – Cincinnati568 New York – Charlotte532

46. Background – Share 35 allocation http://optn.transplant.hrsa.gov/PublicCom ment/pubcommentPropSub_288.pdf

47. Methods outcomes of –waiting list candidates on the waiting list –organ disposition –characteristics of liver transplant candidates –6 m before (12/17/2012 – 6/17/2013) and after (6/18/2013 – 12/18/2013) "Share 35 "

48. Results livers recovered, not Share 35recoveredtransplantedtransplanted pre 26912257 post 32130291 change +52 (19 %)+18 (150 %)+34 (13 %)

49. Results too sick Share 35diedto transplanttotal pre 66 (10 %)120 (18 %)186 post 82 (12.3 %)97 (15 %)179

50. Results regional MELD wait list death Share 35organ share>= 35 + toosick pre 9.0 %18.3 %28 % post 28.5 %32.2 %27 %

51. Results distance procured organ Share 35CITorgan travelled discarded pre 6.2 hrs130 miles 4.5 % post 6.6 hrs162 miles 9.3 %

52. Summary – “Share 35 allocation” Although 19 % more livers were procured, there was no change in the percentage of patients removed from the list for death or too sick to transplant.

53. Summary – “Share 35 allocation” Despite predictions that “Share 35” would improve patient outcomes the opposite is true in UNOS Region 4. Consider these findings as proposals for even larger regional sharing policies are under review.