Embracing the Magic: Increasing Organ Acceptance Rates Through Data Review and Risk Stratification

Embracing the Magic: Increasing Organ Acceptance Rates Through Data Review and Risk Stratification Presented by: Sandy Felty, RN, MSN, MHA Lynette Martin del Campo, RN, MSN, FNP-C Sharon Norfles, RN, BSN

Overview- Kidney Scarcity There are currently 121,678 people waiting for lifesaving organ transplants in the U.S. Of these, 100,791 await kidney transplants. (as of 1/11/16)¹ In 2014, 4,761 patients died while waiting for a kidney transplant. Another, 3,668 people became too sick to receive a kidney transplant On average, 13 people die each day while waiting for a life-saving kidney transplant Despite the high demand for donated kidneys, many of the kidneys procured end up being discarded rather than transplanted. In many instances, the organ could have been successfully transplanted. Strategically accepting marginal offers, based on balancing donor criteria with recipient characteristics allows us to accept a greater number of import offers. Source: ¹National Kidney Foundation 2Keck Hospital of USC

Objective: 1. Define Current Practice 2. Developing Organ Offer Strategies Evaluate Results 3. Summarize: Challenges and Benefits 3Keck Hospital of USC

Define Current Practice Sharon Norfles, RN, BSN 4Keck Hospital of USC

Total Kidney Transplants 2003-2014 Deceased Donor Living Donor All 20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: Hart, A., Smith, J. M., Skeans, M. A., Gustafson, S. K., Stewart, D. E., Cherikh, W. S., Wainright, J. L., Boyle, G., Snyder, J. J., Kasiske, B. L. and Israni, A. K. (2016), OPTN/SRTR Annual Data Report 2014: Kidney. Am J Transplant. 2016;16 (Suppl 2): 11 46. doi: 10.1111/ajt.13666 5Keck Hospital of USC

Kidney Demand vs. Supply 120,000 Waiting List Kidneys Removed Difference 100,000 80,000 60,000 40,000 20,000 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: Hart, A., Smith, J. M., Skeans, M. A., Gustafson, S. K., Stewart, D. E., Cherikh, W. S., Wainright, J. L., Boyle, G., Snyder, J. J., Kasiske, B. L. and Israni, A. K. (2016), OPTN/SRTR Annual Data Report 2014: Kidney. Am J Transplant. 2016;16 (Suppl 2): 11 46. doi: 10.1111/ajt.13666 United Network for Organ Sharing: Wait List Candidates by Organ Type All States July 2, 2016 6Keck Hospital of USC

Kidney Transplant Candidates are Getting Older 18-34 35-49 50-64 65-74 >=75 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: Hart, A., Smith, J. M., Skeans, M. A., Gustafson, S. K., Stewart, D. E., Cherikh, W. S., Wainright, J. L., Boyle, G., Snyder, J. J., Kasiske, B. L. and Israni, A. K. (2016), OPTN/SRTR Annual Data Report 2014: Kidney. Am J Transplant. 2016;16 (Suppl 2): 11 46. doi: 10.1111/ajt.13666 7Keck Hospital of USC

The Waiting Times Are Increasing 100% < 1 year 1-< 2 2-< 3 3-< 4 4-< 5 >= 5 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: Hart, A., Smith, J. M., Skeans, M. A., Gustafson, S. K., Stewart, D. E., Cherikh, W. S., Wainright, J. L., Boyle, G., Snyder, J. J., Kasiske, B. L. and Israni, A. K. (2016), OPTN/SRTR Annual Data Report 2014: Kidney. Am J Transplant. 2016;16 (Suppl 2): 11 46. doi: 10.1111/ajt.13666 8Keck Hospital of USC

Kidney Waitlist 2016 25% 20% 15% 10% 5% 0% < 30 Days 30 to 90 Days 90 Days to 1 Year 6 Months to 1 Year 1 Year to 2 Years 2 Years to 3 Years 3 Year to 5 Years 5 or More Years Source: United Network for Organ Sharing: Wait List Candidates by Organ Type All States July 2, 2016 9Keck Hospital of USC

Kidney Organ Waitlist by State: Waitlist is 3 Years to 5 Years Source: United Network for Organ Sharing: Wait List Candidates by Organ Type All States July 2, 2016 10

Kidney Organ Waitlist by State: Waitlist is More Than 5 Years Source: United Network for Organ Sharing: Wait List Candidates by Organ Type All States July 2, 2016 11

Deceased Donor Kidney Donation Rates (per 1,000 Deaths) 2011-2013 Source: Hart, A., Smith, J. M., Skeans, M. A., Gustafson, S. K., Stewart, D. E., Cherikh, W. S., Wainright, J. L., Boyle, G., Snyder, J. J., Kasiske, B. L. and Israni, A. K. (2016), OPTN/SRTR Annual Data Report 2014: Kidney. Am J Transplant. 2016;16 (Suppl 2): 11 46. doi: 10.1111/ajt.13666 12

Three-Year Outcomes for Adults Waiting for Kidney Transplant New Listings in 2011 Still waiting Removed from list Died DD transplant LD transplant 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0 5 10 15 20 25 30 35 Source: Hart, A., Smith, J. M., Skeans, M. A., Gustafson, S. K., Stewart, D. E., Cherikh, W. S., Wainright, J. L., Boyle, G., Snyder, J. J., Kasiske, B. L. and Israni, A. K. (2016), OPTN/SRTR Annual Data Report 2014: Kidney. Am J Transplant. 2016;16 (Suppl 2): 11 46. doi: 10.1111/ajt.13666 13

Kidneys Recovered 17,000 16,500 16,000 15,500 15,000 16,408 14,500 15,007 15,449 14,000 2013 2014 2015 Source: United Network for Organ Sharing: Wait List Candidates by Organ Type All States July 2, 2016 14

Recovered Kidneys Usage 18,000 All Kidneys Transplanted All Kidneys Recovered but not Transplanted 16,000 14,000 12,000 10,000 2,734 2,888 3,157 8,000 6,000 4,000 2,000 12,273 12,561 13,251 0 2013 2014 2015 Source: United Network for Organ Sharing: Wait List Candidates by Organ Type All States July 2, 2016 15

The Percent of Discarded Kidneys is Growing 19.40% 19.20% 19.00% 18.80% 18.60% 18.40% 19.24% 18.20% 18.00% 17.80% 18.22% 18.69% 17.60% 2013 2014 2015 Source: United Network for Organ Sharing: Wait List Candidates by Organ Type All States July 2, 2016 16

Percentages of Kidneys Not Transplanted Out of All Kidneys Recovered for Transplant 2014 Discharged Transplanted 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% KDPI <= 20\% KDPI 21-34\% KDPI 35-85\% KDPI > 85\% KDPI missing Source: Hart, A., Smith, J. M., Skeans, M. A., Gustafson, S. K., Stewart, D. E., Cherikh, W. S., Wainright, J. L., Boyle, G., Snyder, J. J., Kasiske, B. L. and Israni, A. K. (2016), OPTN/SRTR Annual Data Report 2014: Kidney. Am J Transplant. 2016;16 (Suppl 2): 11 46. doi: 10.1111/ajt.13666 17

Percentages of Kidneys Not Transplanted Out of All Kidneys Recovered for Transplant By KDPI KDPI <= 20\% KDPI 21-34\% KDPI 35-85\% KDPI > 85\% KDPI missing 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: Hart, A., Smith, J. M., Skeans, M. A., Gustafson, S. K., Stewart, D. E., Cherikh, W. S., Wainright, J. L., Boyle, G., Snyder, J. J., Kasiske, B. L. and Israni, A. K. (2016), OPTN/SRTR Annual Data Report 2014: Kidney. Am J Transplant. 2016;16 (Suppl 2): 11 46. doi: 10.1111/ajt.13666 18

Percentages of DCD Kidneys Not Transplanted Out of All Kidneys Recovered Donation after Brain Death Donation After Circulatory Death 19 24 25 18 22 21 23 21 16 22 20 18 14 16 16 16 18 18 19 18 18 18 18 19 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: Hart, A., Smith, J. M., Skeans, M. A., Gustafson, S. K., Stewart, D. E., Cherikh, W. S., Wainright, J. L., Boyle, G., Snyder, J. J., Kasiske, B. L. and Israni, A. K. (2016), OPTN/SRTR Annual Data Report 2014: Kidney. Am J Transplant. 2016;16 (Suppl 2): 11 46. doi: 10.1111/ajt.13666 19

Percentages of Kidneys Not Transplanted Out of All Kidneys Recovered for Transplant By Age <18 18-34 35-49 50-64 >=65 70 60 50 40 30 20 10 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: Hart, A., Smith, J. M., Skeans, M. A., Gustafson, S. K., Stewart, D. E., Cherikh, W. S., Wainright, J. L., Boyle, G., Snyder, J. J., Kasiske, B. L. and Israni, A. K. (2016), OPTN/SRTR Annual Data Report 2014: Kidney. Am J Transplant. 2016;16 (Suppl 2): 11 46. doi: 10.1111/ajt.13666 20

Developing Organ Offer Strategies Sandra Felty RN, BSN, MSN, MHA 21

Given the Constraints on the Supply Side, and the Increasing Demand... There are two possible strategies that can be implemented to increase the utilization of the current kidney supply market: 1. Greater acceptance of marginal kidneys that are offered by local centers. 2. Initiate regional and national allocation earlier to the centers that are more likely to utilize marginal organs due to higher average wait times for transplant. 22

Percentages of Kidneys Not Transplanted Out of All Kidneys Recovered for Transplant 2014 Discharged Transplanted 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% KDPI <= 20\% KDPI 21-34\% KDPI 35-85\% KDPI > 85\% KDPI missing Source: Hart, A., Smith, J. M., Skeans, M. A., Gustafson, S. K., Stewart, D. E., Cherikh, W. S., Wainright, J. L., Boyle, G., Snyder, J. J., Kasiske, B. L. and Israni, A. K. (2016), OPTN/SRTR Annual Data Report 2014: Kidney. Am J Transplant. 2016;16 (Suppl 2): 11 46. doi: 10.1111/ajt.13666 23

More Patients Are Willing To Take Marginal Kidneys (Accept ECD or KDPI >85\% kidney) Yes No 100% 90% 80% 70% 58.1 57.2 56.5 56.2 55.7 55.2 54.6 53.6 52.9 52.2 51.3 50.1 60% 50% 40% 30% 20% 10% 0% 41.9 42.8 43.5 43.8 44.3 44.8 45.4 46.4 47.1 47.8 48.7 49.9 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: Hart, A., Smith, J. M., Skeans, M. A., Gustafson, S. K., Stewart, D. E., Cherikh, W. S., Wainright, J. L., Boyle, G., Snyder, J. J., Kasiske, B. L. and Israni, A. K. (2016), OPTN/SRTR Annual Data Report 2014: Kidney. Am J Transplant. 2016;16 (Suppl 2): 11 46. doi: 10.1111/ajt.13666 24

Over Time, Older Patients Have Become More Willing To Accept a Marginal Kidney 100% 90% 18-34 35-49 50-64 >=65 80% 55.0 57.8 59.3 61.6 63.1 64.3 65.5 66.7 67.6 67.8 68.2 67.7 70% 60% 50% 42.7 43.3 43.7 44.9 45.9 46.1 47.4 48.9 49.7 50.6 51.0 51.6 40% 30% 20% 10% 0% 29.7 29.3 28.9 28.7 28.3 28.0 28.0 28.6 28.8 28.9 29.4 30.7 27.2 25.8 24.5 23.4 22.9 21.6 20.6 20.4 20.0 19.5 20.1 20.8 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: Hart, A., Smith, J. M., Skeans, M. A., Gustafson, S. K., Stewart, D. E., Cherikh, W. S., Wainright, J. L., Boyle, G., Snyder, J. J., Kasiske, B. L. and Israni, A. K. (2016), OPTN/SRTR Annual Data Report 2014: Kidney. Am J Transplant. 2016;16 (Suppl 2): 11 46. doi: 10.1111/ajt.13666 25

Graft Survival Among Adult Kidney Transplant Recipients (In Months) 2009, Deceased Donors KDPI <= 20\% KDPI 21-34\% KDPI 35-85\% KDPI > 85\% 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 Source: Hart, A., Smith, J. M., Skeans, M. A., Gustafson, S. K., Stewart, D. E., Cherikh, W. S., Wainright, J. L., Boyle, G., Snyder, J. J., Kasiske, B. L. and Israni, A. K. (2016), OPTN/SRTR Annual Data Report 2014: Kidney. Am J Transplant. 2016;16 (Suppl 2): 11 46. doi: 10.1111/ajt.13666 26

Import Kidney Offers Accepted by USC 2010 2015 80 y = 7.2286x + 23.867 70 60 50 40 30 20 10 0 2010 2011 2012 2013 2014 2015 Source: UNITED NETWORK FOR ORGAN SHARING Organs offered to CAUH-TX1-KI Includes only organs that were transplanted. Matches run between October 1, 2010 and September 30, 2015 27

Kidney Offers From Outside USC DSA 2010 2015, By KDPI Offer Not Accepted 0-20% 21-34% 35-85% 85-100% Missing Offer Accepted 0-20% 21-34% 35-85% 85-100% Missing 40 35 30 25 40 35 30 25 34 20 15 20 15 25 10 10 5 5 0 2010 2011 2012 2013 2014 2015 0 2010 2011 2012 2013 2014 2015 Source: UNITED NETWORK FOR ORGAN SHARING Organs offered to CAUH-TX1-KI Includes only organs that were transplanted. Matches run between October 1, 2010 and September 30, 2015 28

Accepted Kidney Offers From Outside USC DSA 2010 2015, By KDPI 0-20% 21-34% 35-85% 85-100% Missing 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2010 2011 2012 2013 2014 2015 Source: UNITED NETWORK FOR ORGAN SHARING Organs offered to CAUH-TX1-KI Includes only organs that were transplanted. Matches run between October 1, 2010 and September 30, 2015 29

Kidney Offers From Outside USC DSA 2010 2015, By DCD Donor Status Offer Not Accepted Offer Accepted Not a DCD Yes a DCD Not a DCD Yes a DCD 40 35 30 25 20 15 10 5 40 35 30 25 20 15 10 5 0 2010 2011 2012 2013 2014 2015 0 2010 2011 2012 2013 2014 2015 Source: UNITED NETWORK FOR ORGAN SHARING Organs offered to CAUH-TX1-KI Includes only organs that were transplanted. Matches run between October 1, 2010 and September 30, 2015 30

Accepted Kidney Offers From Outside USC DSA 2010 2015, By Age Group 18-35 Years 36-50 Years 50+ Year 90 80 70 60 50 40 30 20 10 0 2010 2011 2012 2013 2014 2015 Source: UNITED NETWORK FOR ORGAN SHARING Organs offered to CAUH-TX1-KI Includes only organs that were transplanted. Matches run between October 1, 2010 and September 30, 2015 31

Accepted Kidney Offers From Outside USC DSA 2012, By State 14 0-20% 21-34% 35-85% 85-100% 12 10 8 6 4 2 0 California Illinois Minnesota Nevada New York Peruo Rico Texas Source: UNITED NETWORK FOR ORGAN SHARING Organs offered to CAUH-TX1-KI Includes only organs that were transplanted. Matches run between October 1, 2010 and September 30, 2015 32

Accepted Kidney Offers From Outside USC DSA 2013, By State 35 0-20% 21-34% 35-85% 85-100% 30 25 20 15 10 5 0 Arizona California Indiana Louisiana Nevada Texas Utah Source: UNITED NETWORK FOR ORGAN SHARING Organs offered to CAUH-TX1-KI Includes only organs that were transplanted. Matches run between October 1, 2010 and September 30, 2015 33

Accepted Kidney Offers From Outside USC DSA 2014, By State 30 0-20% 21-34% 35-85% 85-100% 25 20 15 10 5 0 Source: UNITED NETWORK FOR ORGAN SHARING Organs offered to CAUH-TX1-KI Includes only organs that were transplanted. Matches run between October 1, 2010 and September 30, 2015 34

Accepted Kidney Offers From Outside USC DSA 2015, By State 14 0-20% 21-34% 35-85% 85-100% Missing 12 10 8 6 4 2 0 Source: UNITED NETWORK FOR ORGAN SHARING Organs offered to CAUH-TX1-KI Includes only organs that were transplanted. Matches run between October 1, 2010 and September 30, 2015 35

Kidney Offers Accepted 2010 2015, By KPDI% and DSA Location Accepted by USC Outside DSA Location <20% 21-34% 35-85% >85% missing <20% 21-34% 35-85% >85% missing 60% 55.00% 60% 50% 50% 50.51% 40% 40% 30% 30% 20% 19.10% 15.40% 20% 15.93% 21.36% 10% 8.10% 10% 10.17% 2.40% 2.03% 0% 0% Source: UNITED NETWORK FOR ORGAN SHARING Organs offered to CAUH-TX1-KI Includes only organs that were transplanted. Matches run between October 1, 2010 and September 30, 2015 36

Observed and Expected Deceased Donor Transplant Rates: 01/01/2013 06/30/2015 Expected (Rate per 100 Person Year) Observed (Rate per 100 Person Years) US 11.5 11.5 Region 9.7 11.4 OPS/DSA 9.6 11.3 This Center 10.8 13.5 0 2 4 6 8 10 12 14 16 Source: Scientific Registry of Transplant Recipients Keck Hospital of USC. Release Data, June 16. 2016 37

First-Year Adult Graft and Patient Survival: 01/01/2013 06/30/2015 Observed Expected Patient Deaths (265 Transplants) 7.48 14.65 Graft Failures (289 Transplants) 4 7 0 2 4 6 8 10 12 14 16 Source: Scientific Registry of Transplant Recipients Keck Hospital of USC. Release Data, June 16. 2016 38

Of Organs Transplanted at USC 31.0% were not from local DSA (20% national) 19.0% were from outside the state of California 21.0% were DCD 13.0% were ECD 72.3% were given to people aged over 50 50% of transplanted organs have a cold time in the range of 20-30 hrs (vs. 37% nationally) 22.5% of kidneys were given to people aged over 65 (vs. 19.1% nationally) More transplants were performed than were expected (0.10% exp vs. 0.13% observed) One year graft survival was also higher than expected (94.2% exp vs. 96.8% observed) 39