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)

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


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



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


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)



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


Pre-KAS Post-KAS



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


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



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.


59.8%

40.2%

61.1%

38.9%

59.0%

41.0%

0%

50%

100%

Male Female

Recipient gender


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



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


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


Post-KAS



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 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


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


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)

the new kidney allocation system (kas): the first six months · performance tracked monthly through...

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