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Modifications to Released Kidney and Pancreas Allocation

Proposal Overview

Status: Public Comment

Sponsoring Committee: Organ Procurement Organization

Strategic Goal: Improve waitlisted patient, living donor, and transplant recipient outcomes

Read the proposal (PDF; 01/2020)

Contact: Pete Sokol

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eye iconAt a glance

What is current policy and why change it?

If a transplant hospital is unable to transplant a kidney or pancreas into the patient they accepted the organ for, they must contact the Organ Procurement Organization (OPO) that offered them the organ so that a new recipient can be found. That “host” OPO has the option to continue offering the organ or they can delegate that responsibility to the “importing” OPO that serves the transplant center that declined the organ. The importing OPO then runs a list of eligible candidates within their Donation Service Area (DSA) to hopefully find another recipient that is close-by.

The OPTN Board of Directors approved policy in December 2019 that removes DSA and region from OPTN kidney and pancreas allocation policy and instead uses a 250 nautical mile (NM) circle with the donor hospital at the center. Having policies for reallocation of a kidney or pancreas that are consistent with the Board-approved changes promotes efficiency and organ utilization.

What’s the proposal?

  • Host OPO would have 2 options when an original recipient can’t receive intended kidney or pancreas:
    • Continue to find a new recipient.
    • Delegate responsibility to the UNOS Organ Center.
  • If host OPO decides to continue to find new recipient, they can:
    • Use the original match run; or
    • Create a new match run based on the transplant hospital that originally accepted the organ.
      • Offer the organ to patients within a 250NM circle of the transplant hospital first.
      • Candidates inside the circle receive up to 2 proximity points based on how close their transplant hospital is to the center of the circle.
      • If no candidate within the circle accepts the organ it would then be offered to patients outside of the circle.
      • These candidates could receive up to 4 proximity points.

What’s the anticipated impact of this change?

  • What it’s expected to do
    • Create a process for reallocation of organs from candidates who cannot be transplanted that aligns with the new kidney and pancreas allocation policies.

Themes to consider

  • The circle size for reallocation.
  • Should the process be the same for kidney and pancreas.
  • Who should be responsible for reallocating the organ(s).

Terms you need to know

  • Match run: A computerized ranking of transplant candidates for an organ being offered based upon donor and candidate medical compatibility and criteria defined in OPTN policies.
  • Nautical Mile: Equal to 1.15 miles and is directly related to latitude and longitude; used in aviation.
  • Proximity Points: additional points given to transplant candidates on a match run based off of the location of their transplant hospital in relation to the center of the allocation circle.  The closer to the center of the circle, the more points a candidate receives.
  • Reallocation:  The process of finding the next suitable transplant candidate for an organ after it has been accepted and then declined for the original intended recipient.
  • Click here to search the OPTN glossary.

Comments

OPTN Region 4 | 02/08/2020

Strongly support (1), Support (16), Neutral/Abstain (1), Oppose (4), Strongly Oppose (0) Comments: Region 4 supported the proposal. There was a suggestion that the committee should consider not including highly sensitized candidates when reallocating to increase efficiency. There was general support for having a different import policy for kidney and pancreas. Many agreed that pancreas programs should be allowed to back up with candidates at the local center given that there are fewer pancreas programs across the country and that pancreas are more sensitive to cold ischemic time. While there was some concern that this could result in gaming, most agreed that it would work as long as allocation was closely monitored to make sure there are not centers with a pattern of accepting for one candidate and transplanting someone different. There was also a suggestion that a third choice could be added that would allow an OPO flexibility based on cold ischemic time.

OPTN Region 6 | 02/18/2020

Strongly support (0), Support (15), Neutral/Abstain (0), Oppose (0), Strongly Oppose (0) The region supported the proposal. There was general consensus that the responsibility for reallocation should remain with the host OPO. Currently Region 6 imports few pancreata or kidney/pancreata, but this could change with removal of DSA and region from allocation policy. Sharing between Seattle and Portland has the potential to increase the net use of these organs in our region.

OPTN Region 8 | 02/18/2020

OPO Committee: Modifications to Released Kidney and Pancreas Allocation • Eliminating local backup could lead to increased discards • Need to consider what the accepting center’s responsibility is when they do not transplant a kidney that they accepted, both financially and statistically • OPOs should be empowered to be more proactive when placing organs that are at risk for non-utilization • There will be concerns with crossmatching materials • Support for host OPO maintaining responsibility for reallocation Vote: 3 Strongly Support, 9 Support, 3 Neutral/Abstain, 4 Oppose, 2 Strongly Oppose

Region 5 | 02/21/2020

Strongly support (0), Support (5), Neutral/Abstain (0), Oppose (20), Strongly Oppose (8) Proposed Amendment: Include provision to allow host OPO to delegate allocation to the receiving center’s OPO Strongly support (6), Support (20), Neutral/Abstain (2), Oppose (1), Strongly Oppose (0) Comments (include discussion during breakouts and general session): Region 5 did not support the proposal as written, but would support it if it were modified to include their suggested amendment. Members had questions regarding metrics and the use of local backup. They also raised numerous transportation concerns as well as the negative effect this would have on cold ischemic time. • You do not want centers to bait and switch. Are there metrics of how many times this should happen at one center? • It could be challenging to work with centers in a different DSA to reallocate a kidney that has a lot of cold time on it • Center or local backup should be allowed • We must consider who is transporting the kidney, policy needs to address who is responsible for moving the kidney • How does expedited allocation (KAPP) work with this? • What happens with the re-allocation of offers through the organ center? • Has there been any modeling for this proposal? • Asked if this was driven by east coast center? • What about responsibility for traveling the kidney around at the destination?