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Eliminate the use of DSA and Region in kidney allocation policy

Proposal Overview

Status: Public Comment

Sponsoring Committee: Kidney Transplantation Committee

Strategic Goal: Provide equity in access to transplants

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Read the proposal (PDF; 8/2019)

View kidney allocation proposal maps (8/2019)

Kidney and Pancreas Distribution Modeling: Analysis at a Glance (8/2019)

Contact: Tina Rhoades

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You may be interested in this proposal if

  • You or your loved one needs a kidney transplant
  • You are a healthcare professional who cares for end stage renal disease patients
  • You work for a kidney transplant program or an Organ Procurement Organization (OPO)

Here’s what we propose and why

The OPTN Kidney Transplantation Committee proposes to remove Donation Service Area (DSA) and regional boundaries used in the current system and allocate using a 500 nautical mile (NM) circle around the donor hospital. Points would be assigned based on how close the candidate’s transplant hospital is to the hospital where the organ donation takes place. This is to prevent a kidney being transported further away when there is a candidate of similar priority closer to the donor hospital. The kidney would first be allocated to all eligible candidates inside the 500 NM circle. If the organ has not been accepted by those candidates, it would then be offered to other eligible candidates.

Location should not hinder access to transplant. The goal of this proposal is to provide consistent distribution units and promote patient access to transplant.

The proposed change would also increase priority for pediatric patients and for prior living donors who now need a transplant. Aside from these changes, kidneys will still be matched with patients according to current criteria.

Why this may matter to you

The goal of this proposal is to increase equity in access for U.S. kidney transplant candidates. Some areas of the country will see an increase in kidney transplants which means other areas will experience a decrease. Some kidneys would have to travel further than they do today, in order to meet this goal. This change would result in new working relationships between OPOs and transplant centers.

Tell us what you think

  • What factors should be used to select a circle size that distributes kidneys broadly and efficiently?
  • Should proximity points be used inside the 500 NM circle? Should they be used outside the distribution circle? How should the assigned values be weighted in relation to other kidney allocation points?
  • What priority do you think is appropriate for pediatric candidates? Should prioritization be applied inside the distribution circle? Should prioritization be applied outside the distribution circle?
  • What priority do you think is appropriate for prior living donor candidates? Should prioritization be applied inside the distribution circle?
  • What operational concerns should the committee consider as this policy is being prepared for OPTN board action and implementation?
  • Should medical urgency criteria be defined? If so, what specific conditions would qualify? Where should the new medically urgent classification be placed within allocation tables? Should placement within allocation tables vary depending on the KDPI of the donor kidney? How should two medically urgent candidates be prioritized should two appear on the same match run?
  • When import back up is granted, do you support the use of an import match run for the import OPO to reallocate the kidney? Should the match run use the same size circle as the original allocation but with increased points for proximity? Should the circle size be smaller? If so, what distance will promote the efficient reallocation of kidneys?


Anonymous | 08/02/2019

What priority do you think is appropriate for prior living donor candidates? I think it is important to maintain or improve priority given to prior living donors. A major concern for living donors and their families and loved ones is what happens if the living donor someday needs a transplant. It is comforting to know that priority is given to prior living donors. I believe that removing or reducing this benefit would reduce the number of people willing to be a living kidney donor.

Anonymous | 08/05/2019

The foundation the geography committee is used to make recommendations is wrong. The entire reason for geographic discrepancies is OPO performance. OPO self report data. When actual data is use Donors per/million or donors/10000 deaths, the data is unbelievable. Am J Transplant. 2019;00:1–6. Goldberg reported. "Our work calls into question the principle that inherent differences in supply leads to geographic inequity in access to transplants using our objective, standardized OPO performance metric. In 2018, 169 patients died or were delisted as too sick in NYRT. If NYRT performed at the same level as the Gift of Life Donor Program in Philadelphia, they would have had an additional 303 organ donors, which would have dramatically decreased the number of patients who died waiting for a liver (and kidney, heart, or lung) transplant in the region. The results of our analysis and the success of other OPOs with changes in their organizational structure suggest that the capacity for this level of performance exists and that unmet need may best be addressed with critical reassessment of local effort rather than reliance on the efforts of others. " UNOS needs to address this fundamental problem. Stop pushing forward with expensive, inefficencent, non effective ideas that decrease the number of transplants and increase the number of discards. With the presidential mandate on organ transplantation. Major goals, decrease discards, get more people transplanted and improve OPO performance. UNOS needs to get on board. The problem is OPO performance. Changing allocation will have a negative effect and make this problem worse. The unitended consequences of lung allocation. No more patients transplant, increased flights, increased costs and worse outcomes. AJT 2019 1-4. V. Puri. One hospital reported and increase in cost of 1.8 million for 7 months after the change. If this was annualized for the national number of 2500 lungs thats 85,000,000 increase in cost one can only imagine the increased cost for kidney transplants with more travel and longer ischemic times. I strongly oppose for the following reasons. Increase cost, decrease efficeincey, decrease number of transplants, increase discards. The main reason. OPO performace is the main problem. This was never addressed so the entire geography committee findings need to be disgarded.

Laura | 08/06/2019

This proposal will greatly reduce transplants in general as the further an organ has to travel and the longer time it is out of the body, the less likely it can be used for successful transplantation. This is a harmful solution. Helpful solutions to this problem include automatic deceased organ registry (with an opt out option) for driver's licenses/IDs and education regarding deceased and living donation, especially in those areas where donation rates are low. Our donors deserve to have their gifts given the best chance to save someone's life.

Ryutaro Hirose | 08/07/2019

I fully support the notion of eliminating DSA and UNOS region from any distribution system in this country for all organs. 1) I disagree with the 500 nm circle - it definitely should not be any smaller but - I am not sure why it 750 nm and even larger ones weren't modelled. They would likely ameliorate geographic disparity to access more effectively and kidneys can clearly travel that distance and be successfully used. 2) I would minimize or preferably eliminate proximity points and the advantage that more local candidates would have (Again, I would eliminate them altogether) Why should a patient within or without any circle be disadvantaged by living or being listed at a center somewhat further than another candidate? Otherwise, I support the effort of the Kidney committee to eliminate the use of illogical and random DSA and Regional boundaries in organ distribution altogether

Randee Bloom | 08/08/2019

Each and every living organ donor provides the gift of life to another, never knowing their personal health future. I believe all organ distribution policies should specifically detail the prioritization methodology should a prior living donor become a listed donor candidate. Specifically, yes, prioritization should be applied to within, and beyond, a designed distribution circle. Our community's system of highly valuing the living donation must match this with highly valuing the living donor's future welfare. A significant level of priority, clearly noted for all potential needed transplants, can provide needed messaging that we highly value the welfare of living donors.

LifeGift | 08/08/2019

Proposed policy is consistent with our support for broader distribution not using arbitrary boundaries. In addition, this policy provided additional consideration for pediatric candidates and prior living donors. Thank you for the opportunity to comment.

Richard Formica | 08/11/2019

I support the OPTN/UNOS Kidney Committee proposed allocation system of Model Number 3 (M3) or “500.500.4.8.”) for the following reasons. 1. The 500 mile distance meets the intention of larger geographic sharing. 2. The outcomes across all the models are essentially the same, likely reflecting the good overall outcomed of kidney transplantation, and therefore, there is no reason to choose a smaller area. 3. The larger circle by encompassing more donors will provide opportunities to transplant more immunologically challenging individuals. 4. The steeper proximity curves (4:8 allocation points) will prevent kidneys from traveling for similar candidates in different locations. Region one used to have population distance points so in effect this experiment has been done. The community must remember that kidneys are not allocated based upon waiting time but rather allocation score. 1 allocation point is equivalent to 1 year of waiting time. Therefore a like candidate (CPRA and DR match) 500 miles away will have to have waited an additional 4 years to pull a kidney from a candidate listed at the hospital the donor was in. 5. I believe that this approach will by necessity force programs to better manage their lists. Better list management, i.e. ensuring candidates are both appropriate and optimized for kidney transplantation, will lead to better outcomes and therefore better stewardship of donated organs. 6. Finally, there is a potential benefit to programs. When population distance points were in place in region 1 (it will remain to be seen if this remains true when the distance and hence population is larger) often a program would have multiple candidates in sequence for a given organ (the proximity points cause this). This allowed the program to decline the organ for a candidate that was not considered appropriate for that type of organ because they knew that the next candidate in sequence who was more appropriate for that organ was also their candidate. Hence better donor - recipient matching. It is my assumption, I have only read the SRTR reports on outcomes and have not seen the Kidney Transplantation Committee's plan to map KAS onto these new geographic subunits, that the allocation for the 100/99/98 % cPRA candidates will now be National/1000/500. If this is the case I would recommend a closer look at the sliding scale points allowed. As we have learned, within that group 98.5+ to 99.4 cPRA there may be too much advantage awarded. Additionally, the 98% candidates, previously receiving DSA priority only, may now not require that given the larger number of patients encompassed and perhaps this group can be addressed by the addition of a certain number of additional allocation points. In lieu of making a more complicated allocation system, perhaps adjusting the points given will correct this.

Wake Forest Baptist Health | 08/13/2019

I don't disagree with the hybrid framework model to replace DSA as a method of kidney distribution but the 500 NM radius is much too large. When I use the interactive map and use our center (NCBG) as the donor hospital, the distribution/proximity circle in essence encompasses nearly all of the continental US east of the Mississippi River! This represents much too large of a geographic area in order to facilitate efficient placement and transplantation of recovered kidneys. The logistics involved in such an undertaking are staggering, cumbersome, and counterproductive to optimal utilization of donor kidneys. I would favor lowering the proximity circle to either 150 or 250 NMs.

Anonymous | 08/13/2019

The proposed changes would disadvantage centers that are not in the middle of the country or at least 500 NM from an ocean or foreign country on all sides. Transplant centers in San Diego would be severely negatively impacted because we will be sending kidneys further away under the new model (to as far north as San Francisco and northeast to Las Vegas). Instead of keeping donor kidneys in San Diego for the recipients in San Diego. There is no option for a "circle" from San Diego as we are bordered by an ocean to the west and Mexico to the south. So, San Diego has basically access to a "quarter" of a circle. There could be the occasional kidney that would come to San Diego from San Francisco, Las Vegas, or Arizona but most of the kidney would be going out.

Anonymous | 08/13/2019

It appears that the better the OPO the more they are punished for doing a great job. Why not leave everything the way it is and try to understand why some OPOs don't have the outcomes others do? Why reward poor producers with more organs? How fair is that?

University of Arkansas | 08/14/2019

Before implementation, we would like to see a model that includes variables such as organ utilization and donation rates of a particular area.... if possible.

Brianne Marchelletta | 08/14/2019

The proposed allocation system fails to address the increased strain that will be forced upon OPOs and the ripple effect that will occur. First, OPOs will see a significant increase in costs for transportation of both cross match materials and kidney shipments since early offers will be going out to centers that are not within reasonable driving distance of the donor hospital. UNOS needs to do better at encouraging or enforcing centers to conduct a virtual cross match rather than slowing down the allocation process and increasing stress on the donor family because a center has to wait for blood to arrive to perform a cross match. As for kidney shipments, more kidneys will be accepted at a greater distances as well, which means that more kidneys will be sent via airlines and are subject to their flight times, fees, delays and routing errors. These factors already increase the costs to OPOs and CIT on kidneys and in some cases result in the discard of the organ, so to increase the number of kidneys being shipped on airlines will only compound the ongoing problem. Even if UNOS could mandate shipping costs with airlines, nothing can be done to improve flight times or to prevent weather/mechanical delays and routing errors that increase the CIT. Another area that has not been addressed is who will be allocating to the centers within the 500NM circle. Currently, an OPO makes all local and regional offers and are then required to pass national points offers over to the Organ Center who can then apply the Minimal Acceptance Criteria screening tool to the match which can expedite placement. If allocation is left to the OPO and the MAC tool cannot be applied then many centers will receive unnecessary offers and allocation time will be increased due to these unnecessary offers. However, if the Organ Center has to be involved in every kidney match to apply the MAC tool then they will be overwhelmed with cases and with current staffing I don't see how they could possibly operate in a timely manner. Overall, I don't see how this model is an improvement to kidney allocation, the predicted data shows a marginal decrease in placement and in no scenario should that be acceptable. The goal is to fully maximize every donor gift, so we cannot say it is acceptable to lose a few for the sake of change. Until improvements are made in transportation availability, required virtual cross matching and OPO use of the Minimal Acceptance Criteria screening tool I cannot support this model as a viable option. Please consider all the repercussions that will be faced by OPOs, transplant centers and ultimately the donor families and recipients who have the most to lose when it comes to time delays and placement failures.

Gwen McNatt | 08/16/2019

The proposed allocation scheme is a disservice to our patients. In the model, this scheme decreases the transplant rate, increases waitlist mortality (39 more deaths) and graft failure as well as increasing time on dialysis. How can we support such outcomes? Additionally, costs and ischemic time will certainly be increased. There is also increased risk of losing kidneys in transportation, which I don’t believe were considered in the model. The local import back-up scheme seems fairly unworkable, it should be redesigned to consider where the kidney is at time of reallocation. We must do better than this. I believe we need to look at OPO performance variation as well as incentives for transplant centers to use high KDPI kidneys.

Live On Nebraska | 08/21/2019

Our only concern with this proposal is in regards to "local backup". Delegating allocation to a receiving OPO seems to be an ineffective solution to best facilitate maximizing kidney placement. The receiving OPO has minimal vested interest and in many cases limited information about the donor organ being allocated. This change will no doubt require changes to staffing models and processes to facilitate the allocation of organs from another OPO. Our recommendation is to pass local backup allocation to the UNOS Organ Center or leave it in the hands of the host OPO to avoid involvement from the receiving OPO.

Anonymous | 08/22/2019

I like the idea of equity; however, I strongly oppose the proposed hybrid model with 500 nm. UNOS identified DSA as the single factor responsible for inequitable Kidney and pancreas organ allocation. The two factors that affect this variable are local OPO performance and transplant rates at local transplant centers. To expedite this new allocation model, UNOS conveniently chose to ignore OPO performance to factor into the model and only chose transplant center rates for the model. Transplant rates are determined by number of transplants per number of waitlisted patients. What was again ignored was the fact that lot of patients who are inactive on the list or status 7 never get transplanted but account for lower transplant rates at the center. A lot of those status 7 patients should not even be on the list. Ideally only patients active on the list should account for transplant rates. So the very basis of modeling is flawed. What this new model does is only reduce transplant rates in high performing centers with high performing OPOs without actually increasing the rates in low performing centers with low performing OPOs. This does not really achieve equity as intended. I would like readers to read this article by Goldberg published in AJT in 2019 which highlights the benefits of improving OPO performance - OPO performance cannot and should not be ignored in this modeling exercise. This is complicated but UNOS needs to do their due diligence instead of doing what is convenient. A UNOS staff member at the Region 5 meeting in Las. Vegas on 8/21/2019 in response to a comment on OPO performance stated this is beyond the scope of the project which is THE WRONG ANSWER. This is going to affect the lives of thousands of transplant recipients so UNOS needs to do their due diligence. This entire modeling exercise as proposed is flawed and so are its results.