The New Kidney Allocation System (KAS): The First Six Months · Performance tracked monthly through...
Transcript of The New Kidney Allocation System (KAS): The First Six Months · Performance tracked monthly through...
The New Kidney Allocation System (KAS): The First Six Months
1
Darren Stewart, MSJohn Beck
Anna Kucheryavaya, MSUNOS Research Department
Prepared forOPTN Kidney Transplantation Committee
September, 2015
Slideset updated 11/3/15
KAS implemented Dec 4, 2014 Key goals: Make better use of available kidneys
Increase transplant opportunities for difficult-to-match patients (increased equity)
Increase fairness by awarding waiting time points based on dialysis start date
Have minimal impact on most candidates
Background
Performance tracked monthly through June (“out of the gate” reports)
Comprehensive, 6-month analysis requested by the kidney committee Pre-KAS period: June 1, 2013 – December 3, 2014 (18 months) Post-KAS period: December 4, 2014 – May 31, 2015 (6 months)
Background
(http://optn.transplant.hrsa.gov)
Full 6-month report available upon request.
Background
Kidney waiting list trends
5
Trends in KAS readiness99.9%98.0%96.2%94.3%
4.0%2.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
11/22/13 1/11/14 3/2/14 4/21/14 6/10/14 7/30/14 9/18/14 11/7/14 12/27/14 2/15/15 4/6/15 5/26/15
Perc
ent o
f Kid
ney
Regi
stra
tions
Date
EPTS data verified (active registrations)
EPTS data verified (all registrations)
CPRA 99-100 approver names (active)
CPRA 99-100 approver names (all)
Type B eligible for A2/A2B (active)
Type B eligible for A2/A2B (all)
12/4
: KAS
Impl
emen
tatio
n
5/27
: KAS
Pha
se I
EPTS scores
CPRA 99-100
A2/A2B
Prior to KAS implementation, centers had entered data to calculate EPTS scores for nearly all patients and had entered signatures verifying unacceptable antigens for over 90% of CPRA 99-100% patients. Table I.1a
109,708 109,585
101,856 101,563
2,917.7
3,217.53,031.9
3,240.03,263.1 3,190.33,066.83,051.3
3,274.03,372.6
2,893.62,802.92,721.3
3,060.03,097.73,281.0
3,045.53,119.7
0
1,000
2,000
3,000
4,000
5,000
0
20,000
40,000
60,000
80,000
100,000
120,000
1/31/14 5/11/14 8/19/14 11/27/14 3/7/15 6/15/15
Regi
stra
tions
Add
ed (p
er 3
0 da
ys)
Tota
l Size
of t
he K
idne
y W
aitli
st (N
)
Date
Trends in the kidney waiting list
The size of the kidney waiting list has plateaued after KAS. New registrations decreased by 4.2%. Table I.1a
Table I.3a
RegistrationsUnique candidates
Trends in the kidney waiting list
The % of registrations on the kidney waiting list in active status has remained relatively constant at about 60%.
60.8% 60.6% 60.6% 60.7% 60.9% 60.9% 60.9% 60.8% 60.8% 60.8% 60.7% 60.6% 60.2% 59.9% 59.9% 59.9% 60.9% 61.0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
12/31/13 2/19/14 4/10/14 5/30/14 7/19/14 9/7/14 10/27/14 12/16/14 2/4/15 3/26/15 5/15/15
Perc
ent o
f Kid
ney
Regi
stra
tions
Date
% of Registrationsin Active Status
12/4
: KAS
Impl
emen
tatio
n
Table I.1a
Month-end “snapshots”
Trends in the kidney waiting listComparing 3 month-end “snapshots” by candidate age and diagnosis
The distribution of registrations on the waiting list by candidate age, race/ethnicity, diagnosis, and other factors has changed little. Table I.2a
0.9% 9.
8%
26.3
%
43.0
%
20.1
%
0.9% 9.
6%
25.5
%
43.0
%
20.9
%
0.9% 9.
3%
25.2
%
43.3
%
21.3
%
0%
25%
50%
0-17 18-34 35-49 50-64 65+Candidate age
5/31/2013 11/30/2014 5/31/2015
32.2
%
21.8
%
6.1%
7.2%
32.8
%
33.2
%
21.5
%
6.1%
7.2%
32.0
%
33.5
%
21.3
%
6.2%
7.0%
32.0
%
0%
25%
50%
DIABETES HYPERTENSIVENEPHROSCLEROSIS
POLYCYSTIC KIDNEYDISEASE
RE-TRANSPLANT/GRAFTFAILURE
OTHER
Candidate Diagnosis
5/31/2013 11/30/2014 5/31/2015
Deceased donor kidney transplants
10
Solitary deceased donor transplants under KASPre vs. post-KAS trends
Transplant volume has increased slightly (about 1%) post-KAS.
899
851.6 838.9
938965.5
841.1
929 926.1
0
500
1000
Jul-13 Nov-13 Feb-14 May-14 Sep-14 Dec-14 Mar-15 Jul-15
Num
ber o
f tra
nspl
ants
per
30-
day
perio
d
KAS
impl
emen
tatio
n
Table II.1a
893.2 903.0
0
500
1000
Pre-KAS (6/1/13-12/3/14) Post-KAS (12/4/14-5/31/15)
Num
ber o
f tra
nspl
ants
per
30-
day
perio
d 1%↑
Over time (per 30 days) On average
(Total N=16,406) (Total N=5,388)
Who’s getting transplanted under KAS?Percentage of Deceased Donor Kidney Transplants by Recipient Age
More young adults (18-49) are receiving kidney transplants.
Still, over half of transplants are going to age 50+ recipients under KAS.
0.9%
9.6%
25.5%
43.0%
20.9%
4.3%
8.9%
23.8%
40.9%
22.2%
3.6%
13.5%
28.5%
37.4%
17.0%
0%
25%
50%
0-17 18-34 35-49 50-64 65+
Recipient age
Waitlist (11/30/2014)Pre-KASPost-KAS
Table 1.2aTable II.1bEras - Pre: 18 months (June 1, 2013 – Dec 3, 2014) Post: 6 months (Dec 4, 2014 – May 31, 2015)
Transplant rates (per active patient-year) by candidate age
Pediatric transplant rate fell slightly, but difference is only borderline statistically significant. Rate is still 5 times higher than for adults.
Transplant rate increase for 18-34 and 35-49, decreased for older patients.
1.15
0.16 0.16 0.18 0.20
0.97
0.250.20
0.16 0.15
0
0.2
0.4
0.6
0.8
1
1.2
< 18 years 18-34 35-49 50-64 65+
Candidate age
Pre-KAS Post-KAS
Table II.12
Rates of receiving and accepting offers by candidate age
Offer rates dropped post-KAS for pediatrics, but acceptance rates remained relatively high. Donor quality increased for pediatric offers (avg KDPI↓).
Offer acceptance rates dropped for older patients and increased for younger adults, most likely due to organ quality (KDPI) differences.
18.6
13.415.1
17.9
20.2
15.4 15.216.9
19.020.6
0
5
10
15
20
25
< 18 years 18-34 35-49 50-64 65+
Offe
rs re
ceiv
ed p
er y
ear
Candidate age
Pre-KAS Post-KAS 6.86
1.26 1.16
1.08 1.06
6.57
1.731.32
0.94 0.810
1
2
3
4
5
6
7
8
< 18 years 18-34 35-49 50-64 65+
% o
f offe
rs a
ccep
ted
Candidate age
Pre-KAS Post-KAS
Offers received Acceptance rates
Table II.13Table III.5
Who’s getting transplanted under KAS?Percentage of Deceased Donor Kidney Transplants by Recipient CPRA
Transplants have increased sharply for CPRA 99-100% patients. Transplants have declined for CPRA=0% and 80-94% patients.
61.8%
22.5%
4.2% 3.1%
8.3%
60.2%
23.9%
10.0%
3.5% 2.3%
55.3%
21.2%
4.9% 3.8%
14.8%
0%
25%
50%
75%
0 1-79 80-94 95-98 99-100
Recipient CPRA
Waitlist (11/30/2014)Pre-KASPost-KAS
Table 1.2aTable II.1b
Transplant rates (per active patient-year) by candidate CPRA
Transplant rates decreased markedly for CPRA 80-94 candidates. Sharp increases for CPRA 99-100 candidates.
Table II.12
0.18 0.190.21 0.20 0.21
0.190.16 0.15
0.55
0.45
0.32
0.22 0.230.20
0.130.09
0.03
0.16 0.17 0.16 0.150.18
0.14 0.150.19 0.18 0.20
0.240.28
0.21 0.20 0.19
0.310.33
0
0.2
0.4
0.6
0.8
0 1-19 20-29 30-39 40-49 50-59 60-69 70-79 80-84 85-89 90-94 95 96 97 98 99 100
Candidate CPRA
Pre-KAS Post-KAS
Offer & accept. rates by candidate CPRA
Offer rate curve smoother post-KAS, and higher for CPRA>95% patients. Offer acceptance rates increase as CPRA increases, both pre/post-KAS
21.6
8.3
0.2
22.5
6.41.8
0
5
10
15
20
25
Offe
rs re
ceiv
ed p
er y
ear
Candidate CPRA
Pre-KAS Post-KAS
7.8
20.2
0.8 3.5
22.3
0
5
10
15
20
25
% o
f offe
rs a
ccep
ted
Candidate CPRA
Pre-KAS Post-KAS
Offers received Acceptance rates
Table II.13Table III.5
CPRA 99-100% recipient “bolus effect”
Table A.1d
Transplants to CPRA 99-100% patients rose sharply after KAS but have been tapering over time, likely due to a bolus effect.
2.4%1.4%1.6%1.8%
3.3%
2.0%1.8%1.6%
3.2%2.3%2.0%
2.9%1.8%
3.5%2.9%2.5%2.8%
2.4%
17.7%
15.7%15.6%
13.4%
14.6%
12.6%
0%
10%
20%
% o
f tra
nspl
ants
to C
PRA
99-1
00%
reci
pien
ts
Transplant date
KAS
impl
emen
tatio
n
Fewer 0-ABDR and 0-DR mismatch transplants occurred in the post-KAS period.
Transplants by HLA mismatch level
8.5%
91.5%
4.5%
95.5%
0%
25%
50%
75%
100%
0 ABDR Mismatch 1+ ABDR Mismatch
Pre-KASPost-KAS
20.0%
80.0%
16.7%
83.3%
0%
25%
50%
75%
100%
0 DR Mismatch 1+ DR Mismatch
Pre-KAS
Post-KAS
Table II.1b
0.045 0.041
0
0.1
0.2
Pre-KAS Post-KAS
0MM
offe
rs p
er a
ctiv
e pa
tient
yea
r
0MM offers decreased 9% post-KAS. Acceptance rates for 0MM offers dropped by 42%.
Offer rates and acc. rates by HLA mismatch level
17.018.3
0
5
10
15
20
Pre-KAS Post-KAS
Non
-0M
M o
ffers
per
act
ive
patie
nt y
ear
Non-0MM 0MM
8%↑
9%↓
1.06 1.060
5
10
15
20
25
30
35
40
Pre-KAS Post-KAS
% o
ffers
acc
epte
d (n
on-0
MM
)
36.4
21.0
0
10
20
30
40
Pre-KAS Post-KAS
% o
ffers
acc
epte
d (0
MM
)
Non-0MM 0MM
42%↓
Rates of receiving offers % of offers accepted
Table II.13Table III.5
Who’s getting transplanted under KAS?Percentage of Deceased Donor Kidney Transplants by Recipient Duration on Dialysis
More transplants are going to long dialysis duration recipients. Fewer preemptive (before dialysis) transplants.
14.9%
9.1%
49.5%
21.3%
5.2%8.8%
11.0%
50.0%
26.1%
4.2%5.1% 6.9%
39.4%35.5%
13.2%
0%
25%
50%
75%
Preemptive 0-1 1-5 5-10 10+
Recipient duration on dialysis (years)
Waitlist (11/30/2014)Pre-KASPost-KAS
Table 1.2aTable II.1b
Offer & accept. rates by candidate time on dialysis
Offer rates increased post-KAS for high dialysis time patients. Offer acceptance rates rose sharply for candidates with 10+ years on
dialysis and dropped sharply for preemptive patients.
16.7 15.016.4
18.619.8
11.614.9 14.7
16.5
20.225.5
18.9
0
5
10
15
20
25
30
Offe
rs re
ceiv
ed p
er y
ear
Candidate duration on dialysis (years)
Pre-KAS Post-KAS
1.40.7
0.91.2
1.6
2.5
0.5 0.6
0.70.9
1.8
6.3
0
1
2
3
4
5
6
7
% o
f offe
rs a
ccep
ted
Candidate duration on dialysis (years)
Pre-KAS Post-KAS
Offers received Acceptance rates
Table II.13Table III.5
High dialysis time recipient “bolus effect”
Table A.1d
Transplants to recipient with 10+ years of dialysis rose sharply after KAS but have been tapering over time, likely due to a bolus effect.
3.9%4.0%4.1%3.1%3.4%
4.3%4.1%3.9%
5.5%
3.8%4.5%4.2%
4.8%4.9%5.0%
3.4%3.7%4.3%
18.6%
16.6%
12.1%
11.1%
12.7%
8.6%
0%
10%
20%
% o
f tra
nspl
ants
to d
ialy
sis>=
10 y
rs r
ecip
ient
s
Transplant date
KAS
impl
emen
tatio
n
Who’s getting transplanted under KAS?Percentage of Deceased Donor Kidney Transplants by Recipient Race/ethnicity
More African Americans are receiving kidney transplants under KAS. Transplants have also increased for Hispanics, but declined for Whites.
34.3%36.5%
7.9%
19.2%
0.6% 1.1% 0.5%
31.5%
42.4%
7.1%
16.9%
0.6%1.1%
0.5%
37.9%
34.2%
6.8%
18.4%
0.6% 1.5% 0.6%0%
25%
50%
Recipient race/ethnicity
Waitlist (11/30/2014)
Pre-KAS
Post-KAS
Table 1.2aTable II.1b
Transplant rates (per active patient-year) by candidate race/ethnicity
Statistically significant increase in transplant rates for African American (AA) candidates, decrease for Caucasian candidates.
Offer rates up 17% and acceptance rates up 6% for AA candidates. Table II.12
0.17
0.22
0.15 0.15
0.190.21
0.18
0.140.16
0.24
0
0.2
0.4
AfricanAmerican
Causasian Asian Hispanic Other
Candidate race/ethnicity
Pre-KAS Post-KAS
Who’s getting transplanted under KAS?Percentage of Deceased Donor Kidney Transplants by Recipient Primary Diagnosis
Transplants have increased for recipients with hypertensive nephrosclerosis as well as patients needing a retransplant.
Transplants have decreased for diabetics and polycystic kidney disease patients.
33.2%
21.5%
6.1% 7.2%
32.0%
27.2%
21.4%
7.9% 6.7%
36.8%
22.5%24.6%
5.5%8.4%
39.1%
0%
25%
50%
Recipient Primary Diagnosis
Waitlist (11/30/2014)Pre-KASPost-KAS
Table 1.2aTable II.1b
Who’s getting transplanted under KAS?Percentage of Deceased Donor Kidney Transplants by Recipient Gender
Transplants to female recipients have increased slightly under KAS. Highly sensitized patients tend to more often be female.
Table 1.2aTable II.1b
59.8%
40.2%
61.1%
38.9%
59.0%
41.0%
0%
50%
100%
Male Female
Recipient gender
Waitlist (11/30/2014)Pre-KASPost-KAS
Who’s getting transplanted under KAS?Percentage of Deceased Donor Kidney Transplants by Recipient Blood Type
The distribution of transplants has changed little by recipient ABO. Slight increases for blood type B and AB patients.
28.4%
16.5%
2.8%
52.3%
37.0%
12.9%
4.9%
45.1%
35.3%
13.3%
6.4%
44.9%
0%
25%
50%
75%
A B AB O
Recipient blood type
Waitlist (11/30/2014)Pre-KASPost-KAS
Table 1.2aTable II.1b
Sharp rise in A2/A2B transplants, though counts still small.
A2/A2B subtype to blood type B recipientsTrends
3 3
1 1
4
0
2
1
0 0
3
7 7
6
10
8
9
0
2
4
6
8
10
12
1/31/2014 3/22/2014 5/11/2014 6/30/2014 8/19/2014 10/8/2014 11/27/2014 1/16/2015 3/7/2015 4/26/2015
Perc
ent o
f Dec
ease
d Do
nor K
idne
y Tr
ansp
lant
s
Date
A2/A2B to B transplants
<--12/4: KAS Implementation
Table II.9
A2/A2BB transplants have increased 4-fold.
A2/A2B subtype to blood type B recipientsPre vs post-KAS summary
Metric Pre-KAS Post-KAS
A2/A2B transplants 34 47
A2/A2B transplants (normalized per year) 22.5 95.8
% of transplants 0.2% 0.9%
Table II.9
0.9%
4.3%3.6%
Pediatrics
8.3%
2.3%
14.8%
0%
15%
CPRA 99-100
0.027% 0.36% 0.30%
Prior living donors
Waitlist (11/30/2014)Pre-KASPost-KAS
Pediatrics, Highly Sensitized, and Prior Living Donors
Proportion of transplants relative to WL prevalence under KAS: CPRA 99-100: 14.8/8.3 = 1.8 PLDs: 0.30/0.028 = 11 Pediatrics: 3.6/0.9 = 4
(N=32) (N=59) (N=16) (N=984) (N=700) (N=192)(N=9,148) (N=171) (N=602)
Eras - Pre: 18 months (June 1, 2013 – Dec 3, 2014) Post: 6 months (Dec 4, 2014 – May 31, 2015)Table 1.2aTable II.1b
Prior living donors’ access to transplantsDeceased donor transplant rates per active patient-year on the WL
Transplant rates for prior living donors are similar pre vs. post KAS and much greater than for other kidney candidate populations.
(* Difference not statistically
significant (p>0.05))
Eras - Pre: 18 months (June 1, 2013 – Dec 3, 2014) Post: 6 months (Dec 4, 2014 – May 31, 2015) Table II.12
Dual kidney transplants have decreased slightly post-KAS.
Single vs. Dual vs. En bloc kidney transplantsPre vs post-KAS summary
Pre-KAS Post-KAS
N % N %
Single 15948 97.2% 5239 97.2%
Dual 144 0.9% 38 0.7%
En bloc 314 1.9% 111 2.1%
Table II.10
The proportion of transplanted deceased donor kidneys used in multi-organ transplants has changed little.
Multi-organ kidney transplantsPre vs post-KAS summary
Multi-organ kidney transplant type
Pre-KAS Post-KAS
N % N %
All 2086 11.3% 694 11.4%
Heart-Kidney 159 1.0% 54 1.0%
Kidney-Pancreas (KP) 1100 6.3% 346 6.0%
Liver-Kidney (SLK) 803 4.7% 288 5.1%
Other 24 0.1% 6 0.1%
Table II.11
Longevity-matching under KASPercentage of Deceased Donor Kidney Transplants by KDPI and Recipient Age
Transplants with KDPI 0-20% and recipient age 18-34: Pre-KAS: 2.5% of transplants / Post-KAS: 6.7% of transplants
Transplants with KDPI 0-20% and recipient age 50+: Pre-KAS: 10% of transplants / Post-KAS: 4% of transplants
KDPI 0-20 KDPI 21-34 KDPI 35-85 KDPI 86-100 KDPI 0-20 KDPI 21-34 KDPI 35-85 KDPI 86-100% % % % % % % % % %
0-17 2.9 0.8 0.6 0.0 4.3 0-17 2.5 0.9 0.2 0.0 3.618-34 2.5 1.9 4.4 0.1 8.9 18-34 6.7 2.4 4.3 0.1 13.535-49 5.5 4.5 13.2 0.6 23.8 35-49 7.3 4.7 15.9 0.6 28.550-64 7.1 6.5 23.6 3.7 40.9 50-64 2.8 6.0 25.4 3.3 37.465 Plus 2.9 2.6 13.1 3.6 22.2 65 Plus 1.0 2.2 10.9 3.0 17.0All 20.9 16.2 54.8 8.1 100.0 All 20.3 16.2 56.5 7.0 100.0
POST-KAS (12/4/2014-5/31/2015)
AGE
KDPI All
PRE-KAS (6/1/2013-12/3/2014)
AGE
KDPI All
Table II.3b
Longevity-matching under KAS Of KDPI 0-20% kidney transplants, 61% are going to EPTS Top 20% recipients
under KAS.
Under KAS, over half (52%) of EPTS Top 20% recipients received a KDPI 0-20% kidney.
Increased percentage of pediatric recipients receiving KDPI<35% kidneys: Pre-KAS (85%) vs. Post-KAS (94%).
However, a higher % of KDPI>85% kidneys are going to patients under age 50 (8.4% vs. 10% after KAS)
Table II.3bTable II.3c
Post-KAS access to transplants by EPTS score
20%
80%
24.6%
75.3%
0%
25%
50%
75%
100%
EPTS 0-20% EPTS 21-100%
Candidate EPTS Score
% Waitlist Post-KAS % transplants
0.20
0.17
0
0.1
0.2
0.3
<=20% >20% (or missing)
Tran
spla
nts p
er a
ctiv
e pa
tient
-yea
r
Candidate EPTS score
Post-KAS
EPTS 0-20% candidates have moderately higher access to transplants than EPTS 21-100% candidates under KAS, including 18% higher transplant rates.
Table 1.2aTable II.1bTable II.12
Post-KAS offer and accept. rates by EPTS score
Surprisingly, offer rates were lower for EPTS 0-20% patients. However, organ quality was better (lower average KDPI) and acceptance rates for
EPTS 0-20% patients were 30% higher than for EPTS 21-100% patients.
16.1
19.0
0
10
20
30
<=20% >20% or missing
Offe
rs re
ceiv
ed p
er a
ctiv
e pa
tient
-yea
r
Candidate EPTS score
Post-KAS
1.3
1.0
0
1
2
<=20% >20% or missing
% o
f offe
rs a
ccep
ted
Candidate duration on dialysis (years)
Post-KAS
Offers received Acceptance rates
Table II.13Table III.5
Geographic distribution of kidney transplants
67.8%12.8%
19.5%
Post-KAS
Local Regional National
78.8%
8.7% 12.5%
Pre-KAS
Local Regional National
More kidneys are being distributed outside recovery OPO’s DSA.
21.2%32.3%
Table II.1b
Cold ischemic times for transplanted kidneys
Average CIT increased 6% from 17.0 to 18.1 hours CIT> 24 hours - Pre-KAS: 18.3%, Post-KAS: 22.9%
1.6%
11.3%
18.2%19.7%
17.7%
13.2%
14.7%
3.6%
1.9%
9.7%
15.4%
18.6%17.5%
14.0%
18.8%
4.1%
0%
25%
0-4 4-8 8-12 12-16 16-20 20-24 24-36 >=36
CIT (hours)
Pre-KAS Post-KAS
Table II.1d(known CIT only)
Geographic distribution of kidney transplants
No significant changes by OPTN region.
3.9%
12.5%13.3%
9.3%
17.1%
4.5%
7.1% 7.2%6.1%
7.9%
11.2%
3.5%
12.6%14.0%
9.8%
18.0%
3.9%
6.6% 6.8%6.2%
7.7%
10.9%
0%
25%
1 2 3 4 5 6 7 8 9 10 11
OPTN Region
Pre-KAS Post-KAS
Table II.6
KDPI distribution of local transplants
Though fewer transplants are occurring locally, approximately the same percentage had KDPI 0-20% kidneys: Pre (22.0%), Post (21.6%)
KDPI 0-2022.0%
KDPI 21-3416.6%KDPI 35-85
54.2%
KDPI 86-1007.2%
Pre-KAS
KDPI 0-2021.6%
KDPI 21-3416.2%KDPI 35-85
57.3%
KDPI 86-1005.0%
Post-KAS
(inferred from Table II.e)
Delayed graft function (DGF) rates
The percentage of recipients requiring dialysis within the first week after transplant increased from 24.5% pre-KAS to 30.8% after KAS.
24.5
30.8
0
10
20
30
40
Pre-KAS Post-KAS
% d
elay
ed g
raft
func
tion
Table II.16
Deceased donor kidney recovery and utilization
44
Deceased kidney donors recovered under KASPre vs. post-KAS trends
Recovered kidney donor volume has increased 4% post-KAS.Table II.1a
Over time (per 30 days) On average
(Total N=11,687) (Total N=3,945)
659.0 641.0613.5
654.0628.9
692.9
0
400
800
May-13 Aug-13 Nov-13 Mar-14 Jun-14 Sep-14 Dec-14 Apr-15 Jul-15
Dece
ased
kid
ney
dono
rs re
cove
red
per 3
0 da
ys
636.3 661.2
0
400
800
Pre-KAS Post-KAS
Dece
ased
kid
ney
dono
rs re
c. p
er 3
0 da
ys
4%↑
Kidney recovery & utilization under KAS
Total kidney donors recovered per month increased 4% (636 to 661). However, the distribution by KDPI has remained very similar.
Percentage of Recovered Deceased Kidney Donors by KDPI
19.4%
14.4%
51.7%
14.5%
18.8%
14.0%
53.0%
14.1%
0%
20%
40%
60%
0-20 21-34 35-85 86-100KDPI
Pre-KAS Post-KAS
Table III.1b
Kidney recovery & utilization under KAS
Kidney discard rates increased by 1.7% points (about 10%). Increase largest for, but not limited to, KDPI>85% kidneys.
Kidney Discard Rate by KDPI
2.3%6.2%
17.4%
55.6%
18.5%
2.0%7.3%
19.2%
61.9%
20.2%
0%
25%
50%
75%
0-20 21-34 35-85 86-100 OverallDiscard rates
Pre-KAS Post-KAS
Table III.3
Kidney recovery & utilization under KAS
Discard rates have returned to pre-KAS levels in recent months.
Kidney Discard Rate by KDPI -- including months 7-10 (Jun – Sep ‘15)
2.3%6.2%
17.4%
55.6%
18.5%
2.0%7.3%
19.2%
61.9%
20.2%
2.7%6.6%
18.4%
56.0%
18.4%
0%
25%
50%
75%
0-20 21-34 35-85 86-100 OverallDiscard rates
Pre-KAS
Post-KAS (mos. 1-6)
Post-KAS (mos. 7-10)
Kidney recovery & utilization under KASKidney Discard Rate by DCD vs. BD
Greater discard rate increase for kidneys from DCD donors.
18.5% 18.3% 18.5%19.9%
22.6%
20.2%
0%
25%
Brain dead DCD Overall
Discard rates
Pre-KAS Post-KAS
Table III.3
Kidney recovery & utilization under KAS
Reasons for discard similar pre vs post-KAS.
Kidney Discard Reasons
33.5%
28.5%
15.0%
7.2%6.1%
2.3% 1.4% 1.2% 1.1% 1.0% 2.7%
35.9%
26.4%
14.8%
5.1%7.1%
3.0%0.9% 1.3% 1.2% 0.5%
3.7%
0%
25%
50%
Discard reasons
Pre-KAS Post-KAS
Table III.4
Accepted Offers Not Transplanted to the Acceptor*
Post-KAS, a smaller percentage of non-local, accepted offers are not going to the acceptor. (This is also true for the subset of CPRA 99-100% non-local acceptances: 26.5%18.2%.)
Table III.6
0.31% 0.40%
32.0% 27.8%
-50%
0%
50%
% o
f acc
epts
not
tran
spla
nted
to a
ccep
tor
Pre-KAS Post-KAS
Local
Non-local
(size of bubbles reflects relative number of accepted offers)
(72% of accepts)
(60% of accepts)
(28%)(40%)
However, substantially more of the accepted offers are non-local under KAS (28% to 40%), which has lead to... (next slide)
(*DonorNet acceptance data may not include all cases and should be interpreted cautiously.)
Accepted Offers Not Transplanted to the Acceptor*
Table III.6
0.31% 0.40%
32.0% 27.8%
-50%
0%
50%
% o
f acc
epts
not
tran
spla
nted
to a
ccep
tor
Pre-KAS Post-KAS
Local
Non-local
(size of bubbles reflects relative number of accepted offers)
(72% of accepts)
(60% of accepts)
(28%)(40%)
9.3% 11.2%...an increase in the overall % of accepts not going to the accepting patient.
This is because the overall numbers (9.3% and 11.2%) are weighted averages of local and non-local offers, and 40% of the weight is non-local in the post-KAS era.
(Example of “Simpson’s Paradox”)
(*DonorNet acceptance data may not include all cases and should be interpreted cautiously.)
Bottom line: More kidneys are not going to the acceptor under KAS. However, this is because more kidneys are being allocated non-locally, not because of less efficient
allocation of shipped kidneys. If the non-local rate had not improved but remained at 32%, the overall rate would have been 12.9%.
Accepted Offers Not Transplanted to the AcceptorPercent Discarded
Just over a third of kidneys accepted but not transplanted to the accepting patient were discarded, pre and post-KAS.
The remaining kidneys were transplanted into another recipient. Table III.6
(72% of accepts)
(60% of accepts)
(28%)(40%)
36.4% 37.2%
0%
25%
50%
75%
100%
Pre-KAS Post-KAS
% o
f kid
neys
not
acc
epte
d by
ac
cept
or th
at w
ere
disc
arde
d
Overall – KAS is meeting key goals Highly successful 6-month pre-KAS preparation period
Decrease in longevity mismatches
Increase in the number of transplants among very highly sensitized patients
Increase in access to transplant for African Americans candidates
“Bolus effects”: the percent of transplants to CPRA 99-100% and dialysis>10 years recipients are both tapering post-KAS Increase in A2/A2BB transplants, but still room for growth Transplant volume up 1%
Summary: First Six Months of KAS
Several trends deserve further attention: Fewer 0MM transplants
Slight drop in pediatric transplants will continue to be tracked closely
Logistical challenges in allocation
Increased CIT and DGF
Increase in discard rates, particularly KDPI>85% kidneys. Rates appear to be returning back to pre-KAS levels based on months 7-10.
Other metrics (e.g., graft survival rates) require additional lag time and will be available in future reports
Summary: First Six Months of KAS (cont’d)