lung allocation score system update
DESCRIPTION
LUNG ALLOCATION SCORE SYSTEM UPDATE. Current Lung Allocation System. System was implemented on May 4, 2005 The Lung Allocation Score (LAS) is based on a combination of Expected survival in next year without a transplant and Expected survival during 1 st year with a transplant - PowerPoint PPT PresentationTRANSCRIPT
LUNG ALLOCATION SCORE SYSTEM
UPDATE
Current Lung Allocation System
System was implemented on May 4, 2005
The Lung Allocation Score (LAS) is based on a combination of • Expected survival in next year without a
transplant and • Expected survival during 1st year with a transplant
Details of calculation and allocation can be found in Policy 3.7.6
Components Of Current Lung Allocation System:Diagnosis Groups
Diagnosis group
Diagnoses
A COPD/Emphysema; Alpha-1 Antitrypsin Deficiency; Bronchiectasis; LAM; Sarcoidosis with PA mean < 30; Primary Ciliary Dyskinesia
B PPH; Eisenmenger's; Scleroderma (primarily Pulmonary HTN)
C CF; Hypogammaglobulinemia
D IPF; Sarcoidosis with PA mean > 30; Lung retransplant; Obliterative Bronchiolitis (OB); Pulmonary Fibrosis (not IPF); Eosinophilic granuloma; Amyloidosis; Mixed Connective Tissue Disease; Scleroderma (primarily restrictive)
Number Of Lung And Heart-lung Registrations By LAS Status
Active Registrations 12+ Years
408 369 335 331 318 310 304 289 281
1269 1270 1256 1238 1222 1202 1191 1181 1182 1162
349
0
200
400
600
800
1000
1200
1400
1600
1800
5/4 5/11 5/18 5/25 6/1 6/8 6/15 6/22 6/29 7/6
LAS = 0
LAS > 0
Lu
ng
an
d H
ea
rt-L
un
g R
eg
istr
ati
on
s
N=1443N=1667
Active Lung And Heart-Lung Registrations (12+) On July 6, 2005, By Region
106
210
53
112
22
208
240
136
85
121
150
0
25
50
75
100
125
150
175
200
225
250
275
1 2 3 4 5 6 7 8 9 10 11
Region
Lu
ng
an
d H
eart
-Lu
ng
Reg
istr
atio
ns
LAS for Active Lung And Heart-Lung Registrations (12+) With Nonzero Scores
On July 6, 2005, by Diagnosis Group
Age GroupDiagnosis
GroupN
Median Score
Adult (18+)
ALL 1104 33.12
A (COPD) 506 32.16
B (PPH) 115 32.39
C (CF) 163 34.21
D (IPF) 320 36.26
Pediatric(12-17)
ALL 58 33.54
A (COPD) 4 32.13
B (PPH) 13 31.49
C (CF) 31 33.95
D (IPF) 10 36.46
Percent Of Lung and Heart-Lung Transplants Pre- And Post- Policy Implementation
By Diagnosis group
0
10
20
30
40
50
60
A (COPD) B (PPH) C (CF) D (IPF)
Per
cen
t o
f T
ran
spla
nts
5/5/2004-7/5/04 5/5/2005-7/5/2005
Lung Utilization
May 4, 2004 – June 3, 2004
May 4, 2005 – June 3, 2005
N% of
donorsN
% of donors
Deceased donors
Donors 606 100.0 671 100.0
Donors with at least 1 lung transplanted
82 13.5 113 16.8
N% of lungs
N% of lungs
Deceased donor lungs
Lungs (2*donors) 1212 100.0 1342 100.0
Lungs transplanted 149 12.3 205 15.3
Percent of Lungs Transplanted* May 4, 2005 – June 3, 2005
0
20
40
60
80
100
1 2 3 4 5 6 7 8 9 10 11
Region
Per
cen
t o
f L
un
gs
Tra
nsp
lan
ted
* Percent = # Lungs transplanted / donors*2
Evaluation of National Kidney Allocation Policy
after the Elimination of HLA-B Matching Points
Background
On May 7, 2003, the kidney allocation system was modified so that:
No points for HLA-B matches
2 points for zero HLA-DR mismatches
1 point for one HLA-DR mismatches.
Previously:
7 points for zero HLA-BDR mismatch
5 points for one HLA-BDR mismatch
Data/Methods
Deceased donor kidney alone transplants performed at 35 DSA’s (with standard HLA points) between 5/7/02 and 5/6/04 were included.
Pediatric recipients and recipients of expanded criteria donor (ECD) kidneys were excluded from the analysis.
Data/Methods
Compare percentage of transplants by ethnicity, HLA MM level, PRA, wait time, and graft survival in two periods:
Pre-policy period: 5/7/02-5/6/03N = 3,236
Post-policy period: 5/7/03-5/6/04N = 3,001
Non-Zero MM Transplantsby Policy Period and Ethnicity
49.5
32.3
11.84 2.4
124.9 2.9
44.635.6
0
20
40
60
80
100
White Black Hispanic Asian Other
Per
cen
t o
f T
ran
spla
nts
Pre-Policy Post-Policy
P=0.002
Non-Zero MM Transplantsby Policy Period and HLA DR MM
23.2
48.2
28.6
14.3
54.7
31
0
20
40
60
80
100
0 DR MM 1 DR MM 2 DR MM
Per
cen
t o
f T
ran
spla
nts
Pre-Policy Post-Policy
P<0.001
Non-Zero MM Transplantsby Policy Period and HLA MM
3.312.3
25.6
1.1
36.2
27.3
11.719.8
31.8
12.24.1
14.7
0
20
40
60
80
100
1 MM 2 MM 3 MM 4 MM 5 MM 6 MM
Per
cen
t o
f T
ran
spla
nts
Pre-Policy Post-Policy
P<0.001
Non-Zero MM Transplantsby Policy Period and Peak PRA (%)
3.7
79
10.4 7.33.8
74
12 9.9
0
20
40
60
80
100
Not Reported 0% - 20% 21% - 79% 80%+
Per
cen
t o
f T
ran
spla
nts
Pre-Policy Post-Policy
P<0.001
Non-Zero MM Transplantsby Policy Period and Wait Time
37.9
23.4 26.4
12.4
30.323.3
31.7
14.7
0
20
40
60
80
100
<=1 yr 1- 2 yrs 2 - 4 yrs >4 yrs
Per
cen
t o
f T
ran
spla
nts
Pre-Policy Post-Policy 1
P<0.001
Kaplan-Meier Graft Survivalby Policy Period
50
60
70
80
90
100
0 3 6 9 12 15
Su
rviv
al (
%)
Pre-Policy Post-Policy
P=0.20
Summary
Compared with pre-policy period:
More minority candidates received a non-zero MM kidney transplant.
More transplants with worse HLA DR MM. More transplants with PRA > 80%. More transplants with longer waiting times. Graft survival rates were similar.
Evaluation of National Liver Allocation Policy
after the Implementation of Share 15 Policy
Background
On January 12, 2005, the liver allocation system was modified:Local – Status 1A, Status 1BRegional – Status 1A, Status 1BLocal – MELD/PELD > 15Regional – MELD/PELD > 15Local – MELD/PELD < 15Regional – MELD/PELD < 15National – Status 1A, Status 1B, MELD/PELD
Previously:Local – Status 1A, Status 1BRegional – Status 1A, Status 1BLocal – MELD/PELDRegional – MELD/PELD National – Status 1A, Status 1B, MELD/PELD
Adult Deceased Donor Liver Transplants Pre-Policy Period: 1/12/04 – 5/11/04
0
50
100
150
200
250
300
1 2 3 4 5 6 7 8 9 10 11
Region
Nu
mb
er o
f T
ran
spla
nts
MELD < 15 MELD >= 15 Status 1
Adult Deceased Donor Liver Transplants Post-Policy Period: 1/12/05 – 5/11/05
0
50
100
150
200
250
300
1 2 3 4 5 6 7 8 9 10 11
Region
Nu
mb
er o
f T
ran
spla
nts
MELD < 15 MELD >= 15 Status 1
Adults Removed for Death/Too Sick from Liver Waiting List
Pre-Policy Period: 1/12/04 – 5/11/04
0
20
40
60
80
100
120
1 2 3 4 5 6 7 8 9 10 11
Region
Nu
mb
er o
f C
and
idat
es
MELD < 15 MELD >= 15 Status 1
Adults Removed for Death/Too Sick from Liver Waiting List
Post-Policy Period: 1/12/05 – 5/11/05
0
20
40
60
80
100
120
1 2 3 4 5 6 7 8 9 10 11
Region
Nu
mb
er o
f C
and
idat
es
MELD < 15 MELD >= 15 Status 1
Death Rates per 1000 Patient DaysLiver Candidates on the Waiting List
During 9/12/04 - 5/11/05By Age at Listing and Policy Period
0.45
0.15 0.14
0.43 0.4
0.54
0
0.4
0.8
1.2
0 - 11 12 - 17 18 +
De
ath
Ra
te p
er
10
00
pa
tie
nt
da
ys
9/12/04 - 1/11/05 1/12/05 - 5/11/05
Organs Transplanted Locally vs. Non-Locally
What percentage of organs are transplanted outside the DSA?• Some are offered and refused locally, but are
ultimately transplanted outside the DSA
• Others are offered outside the DSA first (no local patients, Status 1 liver shares, 0MM kidneys, Statewide shares, etc.)
How well do these organs function?• UNetsm Utility for Recovering OPOs
• Overall survival rates shown here (adult donors, excluding repeat txs and multiorgan txs)
Kidney Transplants from Adult Donorsby Region of Recovery
2003 - 2004
0200400600800
100012001400160018002000
1 2 3 4 5 6 7 8 9 10 11
Region of Recovery
Nu
mb
er o
f T
ran
spla
nts
Local Non-Local
Kidney Transplants from Adult Donorsby Region of Recovery
2003 - 2004
0
500
1000
1500
2000
2500
3000
1 2 3 4 5 6 7 8 9 10 11
Region of Recovery
Nu
mb
er o
f T
ran
spla
nts
Local Non-Local, No Local Refusals Non-Local, Locally Refused
Kidney Transplants from Adult Donorsby Region of Recovery
2003 - 2004
0
500
1000
1500
2000
2500
3000
1 2 3 4 5 6 7 8 9 10 11
Region of Recovery
Nu
mb
er
of
Tra
ns
pla
nts
Local No Local Refusal, Tx in RegionNo Local Refusal, Tx Out of Region Locally Refused, Tx in RegionLocally Refused, Tx Out of Region
Kidney Transplant* Graft Survival 2003-2004
0
20
40
60
80
100
0 3 6 9 12Months Post Transplant
Su
rviv
al R
ate
(%)
Local Non-Local, No Local Refusal Non-Local, Locally Refused
* Adult donors only, excluding multiorgan and repeat transplants.
P<0.001
Heart Transplants from Adult Donorsby Region of Recovery
2003 - 2004
0
50
100
150
200
250
300
350
400
450
1 2 3 4 5 6 7 8 9 10 11
Region of Recovery
Nu
mb
er o
f T
ran
spla
nts
Local Non-Local
Heart Transplants from Adult Donorsby Region of Recovery
2003 - 2004
0
100
200
300
400
500
600
1 2 3 4 5 6 7 8 9 10 11
Region of Recovery
Nu
mb
er o
f T
ran
spla
nts
Local Non-Local, No Local Refusals Non-Local, Locally Refused
Heart Transplants from Adult Donorsby Region of Recovery
2003 - 2004
0
100
200
300
400
500
600
1 2 3 4 5 6 7 8 9 10 11
Region of Recovery
Nu
mb
er
of
Tra
ns
pla
nts
Local No Local Refusal, Tx in RegionNo Local Refusal, Tx Out of Region Locally Refused, Tx in RegionLocally Refused, Tx Out of Region
Heart Transplant* Patient Survival 2003-2004
0
20
40
60
80
100
0 3 6 9 12Months Post Transplant
Su
rviv
al R
ate
(%)
Local Non-Local, No Local Refusal Non-Local, Locally Refused
* Adult donors only, excluding multiorgan and repeat transplants.
P=0.2
Liver Transplants from Adult Donors by Region of Recovery
2003 - 2004
0
200
400
600
800
1000
1200
1 2 3 4 5 6 7 8 9 10 11
Region of Recovery
Nu
mb
er o
f T
ran
spla
nts
Local Non-Local
Liver Transplants from Adult Donors by Region of Recovery
2003 - 2004
0
200
400
600
800
1000
1200
1400
1600
1800
1 2 3 4 5 6 7 8 9 10 11
Region
Nu
mb
er o
f T
ran
spla
nts
Local Non-Local, No Local Refusals Non-Local, Locally Refused
Liver Transplants from Adult Donorsby Region of Recovery
2003 - 2004
0200400600800
10001200140016001800
1 2 3 4 5 6 7 8 9 10 11
Region of Recovery
Nu
mb
er
of
Tra
ns
pla
nts
Local No Local Refusal, Tx in RegionNo Local Refusal, Tx Out of Region Locally Refused, Tx in RegionLocally Refused, Tx Out of Region
Liver Transplant* Graft Survival 2003-2004
0
20
40
60
80
100
0 3 6 9 12Months Post Transplant
Su
rviv
al R
ate
(%)
Local Non-Local, No Local Refusal Non-Local, Locally Refused
* Adult donors only, excluding multiorgan and repeat transplants.
P=0.007
Lung Transplants from Adult Donorsby Region of Recovery
2003 - 2004
020406080
100120140160180200
1 2 3 4 5 6 7 8 9 10 11
Region of Recovery
Nu
mb
er o
f T
ran
spla
nts
Local Non-Local
Lung Transplants from Adult Donorsby Region of Recovery
2003 - 2004
0
50
100
150
200
250
300
350
1 2 3 4 5 6 7 8 9 10 11
Region of Recovery
Nu
mb
er o
f T
ran
spla
nts
Local Non-Local, No Local Refusals Non-Local, Locally Refused
Lung Transplants from Adult Donorsby Region of Recovery
2003 - 2004
0
50
100
150
200
250
300
350
1 2 3 4 5 6 7 8 9 10 11
Region of Recovery
Nu
mb
er
of
Tra
ns
pla
nts
Local No Local Refusal, Tx in RegionNo Local Refusal, Tx Out of Region Locally Refused, Tx in RegionLocally Refused, Tx Out of Region
Lung Transplant* Patient Survival 2003-2004
0
20
40
60
80
100
0 3 6 9 12Months Post Transplant
Su
rviv
al R
ate
(%)
Local Non-Local, No Local Refusal Non-Local, Locally Refused
* Adult donors only, excluding multiorgan and repeat transplants.
P=0.17
HHS PART Goals
Performance Assessment and Review Tool (PART)
10 year and annual programmatic goals Increase donors, transplants, life years
gained for kidney tx, reduce costs per tx Very aggressive annual goals
400
450
500
550
600
650
700
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Org
an D
onors
1999 2000 2001 2002 2003 2004 2005
Monthly National Donation Monthly National Donation RatesRates
Collaborative Collaborative Starts HereStarts Here
HRSA’S PART Goals
Increase the number of deceased donor organs transplanted
Increase the number of non-DCD donors Increase the number of DCD donors Increase the average number of organs
transplanted per non-DCD donor Increase the average number of organs
transplanted per DCD donors
HRSA’s PART GOALS Increase the number of deceased donor
organs transplanted each year until 42,800 are transplanted in 2013
01000020000300004000050000
1990 1995 2000 2005 2010 2015
Year
Actual PART Goals
Org
ans
Txe
d
HRSA’s PART GOALS
Increase the number of non-DCD donors each year until 9251 is achieved in 2013
02000400060008000
10000
1990 1995 2000 2005 2010 2015Year
Actual PART Goals
# N
on
-DC
D
HRSA’s PART GOALS Increase the number of DCD donors each
year until 2018 is achieved in 2013
0
500
1000
1500
2000
2500
1993 1998 2003 2008 2013
Year
# D
CD
Actual PART Goals
HRSA’s PART GOALS Increase the average number of organs
transplanted per non-DCD donors each year by 0.080 to reach 4.0 in 2013
2.52.72.93.13.33.53.73.94.1
1990 1995 2000 2005 2010 2015
Year
Actual PART Goals
Avg
. Tx/
Do
no
r
HRSA’s PART GOALS Increase the average number of organs
transplanted per DCD donors each year by
0.096 to reach 3.0 in 2013
1.5
2
2.5
3
3.5
1993 1998 2003 2008 2013Year
Actual PART Goals
Avg
. Tx/
Do
no
r
HRSA’s PART GOALS
Increase the total expected life-years gained for kidney transplant recipients in the first 5 years after transplant compared to what would be
expected had they remained on the waiting list
020004000
60008000
10000
2002 2004 2006 2008 2010 2012 2014
Year
LY
Gai
ned
121 % Increase
HRSA’s PART GOALS Increase the average number of years of life
gained in the first 5 years after the transplant for deceased kidney/kidney-pancreas transplanted by 0.003 life-years until the goal of 0.436 life-years gained per transplant is achieved in 2013
0.390.4
0.410.420.430.44
2000 2002 2004 2006 2008 2010 2012 2014
Year
Avg
LY
Gai
ned
8.7 % Increase
Transplants from DCD DonorsJuly, 2004 – June, 2005
236
22 9 4
651
0
100
200
300
400
500
600
700
Kidney Liver Kidney-Pancreas
Lung Pancreas
Nu
mb
er o
f T
ran
spla
nts
DCD Kidney TransplantsJuly, 2003 – June, 2005
0
20
40
60
80
100
120
140
1 2 3 4 5 6 7 8 9 10 11
Region
Nu
mb
er o
f T
ran
spla
nts
7/1/2003-6/30/2004 7/1/2004-6/30/2005
DCD Kidney-Pancreas TransplantsJuly, 2003 – June, 2005
0
2
4
6
8
10
12
14
1 2 3 4 5 6 7 8 9 10 11
Region
Nu
mb
er o
f T
ran
spla
nts
7/1/2003-6/30/2004 7/1/2004-6/30/2005
DCD Liver TransplantsJuly, 2003 – June, 2005
05
101520253035404550
1 2 3 4 5 6 7 8 9 10 11
Region
Nu
mb
er o
f T
ran
spla
nts
7/1/2003-6/30/2004 7/1/2004-6/30/2005
DCD Lung TransplantsJuly, 2003 – June, 2005
0
1
2
3
4
5
6
7
8
1 2 3 4 5 6 7 8 9 10 11
Region
Nu
mb
er o
f T
ran
spla
nts
7/1/2003-6/30/2004 7/1/2004-6/30/2005
Transplants from ECD DonorsJuly, 2004 – June, 2005
60 7
1,395
1071
1,472
10
200
400
600
800
1000
1200
1400
1600
HLHea
rt
Kidne
yKP
Liver
Lung
Pancr
eas
Nu
mb
er o
f T
ran
spla
nts
ECD Kidney TransplantsJuly, 2003 – June, 2005
0
50
100
150
200
250
300
1 2 3 4 5 6 7 8 9 10 11
Region
Kid
ney
Tra
nsp
lan
ts
7/1/2003-6/30/2004 7/1/2004-6/30/2005
Kidney Transplant Graft Survival 2000-2003
U.S.
0
20
40
60
80
100
0 1 2 3Years Post Transplant
Su
rviv
al R
ate
(%)
SCD DCD ECD
Liver Transplant Graft Survival 2000 - 2003
U.S.
0
20
40
60
80
100
0 1 2 3Years Post Transplant
Su
rviv
al R
ate
(%)
SCD DCD ECD
DCD Donors by Month2003 – June, 2005
0
10
20
30
40
50
60
Jan0
3M
ar03
May
03Ju
l03
Sep03
Nov03
Jan0
4M
ar04
May
04Ju
l04
Sep04
Nov04
Jan0
5M
ar05
May
05
Nu
mb
er o
f D
on
ors
ECD Donors by Month2003 – June, 2005
0
20
40
60
80
100
120
140
160
180
200
Jan0
3M
ar03
May
03Ju
l03
Sep03
Nov03
Jan0
4M
ar04
May
04Ju
l04
Sep04
Nov04
Jan0
5M
ar05
May
05
Nu
mb
er o
f D
on
ors
Organs Recovered Per Donor by Donor Type1995 – June, 2005
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Org
ans
Rec
ove
red
per
Do
no
r
Standard ECD DCD
3.9
2.8
2.6
Organs Transplanted Per Donor by Donor Type1995 – June, 2005
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Org
ans
Tra
nsp
lan
ted
per
Do
no
r
Standard ECD DCD
3.6
2.0
1.8