Status: Committee Review
Sponsoring Committee: Pancreas Transplantation
Strategic Goal: Increase the number of transplants
Pancreas Committee Board briefing paper (PDF - 434 K; 12/2017)
Pancreas transplants continue to decline and the majority of pancreata that are transplanted are done so as part of a simultaneous pancreas-kidney (SPK) transplant. Current blood type restrictions on kidney-pancreas allocation prevent clinically compatible SPK transplants from occurring. Preventing clinically compatible SPK transplants results in many of these pancreata being discarded or not recovered. Modifying current blood type restrictions could lead to an increase in the utilization of pancreata, an overall increase in SPK transplants, and could promote a more efficient allocation system.
This proposal modifies Policy 11.4.D Blood Type for Kidney-Pancreas Allocation to loosen restrictions on blood type compatibility for kidney-pancreas (KP) and pancreas alone (PA) allocation: allowing blood type A, non-A1 and AB, non-A1B kidney-pancreas and pancreas offers to B candidates, allowing blood type B kidney-pancreas and pancreas offers to AB candidates, and removing restrictions on blood type O compatibility. The proposal also modifies allocation to prioritize high-cPRA ABO-identical candidates above high-cPRA ABO-compatible candidates, then among candidates with cPRA < 80%, prioritize ABO-identical candidates above ABO-compatible candidates.
The Pancreas Committee is pursuing an allocation change that maximizes the increase of KP transplants and minimizes negative impacts on blood type, age, or ethnicity. While the modeling by the Scientific Registry of Transplant Recipients (SRTR) did not project that candidates would be disadvantaged based on age or ethnicity, the modeling projected a slight reduction in blood type O access to transplant, including a simulated 2% decrease for blood type O kidney transplants. There was also a decrease for KP blood type O transplants but an increase of KPs overall. However, the modeling projected a significant increase in the number of SPKs, an increase in the number of median years of benefit, and a net increase in transplants if the blood type restrictions were loosened. The simulation chosen by the Committee predicts the least impact on blood type O candidates except one (Run 6), which showed a smaller increase in the median years of benefit and life years from transplant (LYFT). The increase in SPKs and net increase in transplants projected by the proposal aligns with OPTN Goal 1, to increase the number of transplants.
Read the full proposal (PDF - 758 K)
There is no available data on transplanting a blood type A, non-A1 and AB, non-A1B kidney-pancreas or pancreas alone into a blood type B recipient, because these transplants have not been previously permitted by OPTN/UNOS policy. In seeking to encourage the use of this compatibility, the Committee seeks feedback on any concerns, questions or experiences that members of the transplant community may have on transplants involving A, non-A1 and AB, non-A1B kidney-pancreas or pancreas alone into blood type B recipients. This feedback will help the Committee create an educational resource for the community to use in conjunction with this policy change.
Also in regards to the A, non-A1 and AB, non-A1B to B compatibility, the Committee asks whether transplant programs anticipate using different titer thresholds for an A, non-A1 and AB, non-A1B kidney-pancreas or pancreas alone compared to the titer thresholds used for an A, non-A1 and AB, non-A1B kidney alone. The programming for this policy would allow transplant programs to indicate a candidate’s eligibility to receive blood type A, non-A1 and AB, non-A1B organs for kidney, kidney-pancreas, and pancreas. If the kidney-pancreas or pancreas titer thresholds differ, then the eligibility for receiving these organs should be submitted separately.
- VERY LARGE: UNOS IT effort to modify several sections of the waitlist is estimated at 2,880 hours
- Ongoing effort for UNOS is very small
- Minimal impact for hospitals
- One month to implement upon programming for members
- Staff time to adjust protocol and develop education is minimal cost
- Ongoing cost is dependent on change in pancreas transplant volume
IT Implementation is very large and includes 2,880 hours to modify several places on the waitlist referencing A2/A2B candidate eligibility. Instructional Innovations will produce an instructional offering to compliment the policy change. Ongoing effort is very small for IT, Research, and Member Quality.
- Hospital: The implementation effort is minimal and requires some clinical and administrative time. It is unlikely to require additional hours among salaried staff. Staff will develop local protocol, consent procedures, and waitlist analysis to determine eligibility to implement the change in policy. Development of patient education may also be a small cost to produce. Maintaining candidate eligibility on the waitlist, such as repeat titer testing, may include some additional staff time. This additional staff time to establish the change could total several thousand dollars.
Change in volume of pancreas transplants is the major variable that may cause additional cost. This is unlikely, however, as pancreas transplant volume is historically lower and less variable than other transplant volume.
There is a possibility to reduce blood type B candidate waitlist time, but other blood type candidates may consequently wait longer, so savings may not materialize.
- Lab and OPO: Minimal or no impact.