The Kidney Allocation System (KAS) - The First Two Years · The Kidney Allocation System (KAS) The First Two Years Amber R. Wilk, PhD John Beck Anna Y. Kucheryavaya, MS United Network

The Kidney Allocation System (KAS)The First Two Years

Amber R. Wilk, PhDJohn Beck

Anna Y. Kucheryavaya, MS

United Network for Organ Sharing

Prepared for OPTN Kidney Transplantation CommitteeApril 19, 2017

Background

‚ KAS implemented December 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

2

Background

‚ Performance tracked monthly through June (“out of the gate” reports)‚ Six month report completed September 2015‚ One year report completed April 2016‚ Two year analysis now completed

‚ Post-KAS years only, comparing Post-KAS Year 1 to Post-KAS Year 2‚ Post-KAS Year 1: December 4, 2014 - December 3, 2015‚ Post-KAS Year 2: December 4, 2015 - December 3, 2016‚ New: DGF rates, stratified‚ New: One-year survival outcomes, overall and stratified‚ New: Relisting rates pre- vs. post-KAS

3

Kidney Waiting List Trends

4

Trends in the Kidney Waiting ListRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrations

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12/4

/14:

KA

S Im

plem

ente

d

0

30000

60000

90000

120000

Mar

−201

4

May

−201

4

Jul−2

014

Sep−2

014

Nov−2

014

Jan−

2015

Mar

−201

5

May

−201

5

Jul−2

015

Sep−2

015

Nov−2

015

Jan−

2016

Mar

−201

6

May

−201

6

Jul−2

016

Sep−2

016

Nov−2

016

Jan−

2017

Date

Tota

l Siz

e of

the

Kid

ney

Wai

tlist

(N

)

The size of the kidney waiting list is slowly yet steadily decreasing; less than 1% new kidney registrations were added post−KAS Year 2 vs.Year 1.

Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)

0

1000

2000

3000

4000

5000

Reg

istr

atio

ns A

dded

(pe

r 30

day

s)

RegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrationsRegistrations

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12/4

/14:

KA

S Im

plem

ente

d

0

30000

60000

90000

120000

Mar

−201

4

May

−201

4

Jul−2

014

Sep−2

014

Nov−2

014

Jan−

2015

Mar

−201

5

May

−201

5

Jul−2

015

Sep−2

015

Nov−2

015

Jan−

2016

Mar

−201

6

May

−201

6

Jul−2

016

Sep−2

016

Nov−2

016

Jan−

2017

Date

Tota

l Siz

e of

the

Kid

ney

Wai

tlist

(N

)

The size of the kidney waiting list is slowly yet steadily decreasing; less than 1% new kidney registrations were added post−KAS Year 2 vs.Year 1.

Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)Registrations added (per 30 days)

0

1000

2000

3000

4000

5000

Reg

istr

atio

ns A

dded

(pe

r 30

day

s)

5

Changes in Dialysis Listing Patterns, Post-KAS

2.44%

−4.26%

3.66%

−2.06%

−0.17%

−5.0

−2.5

0.0

2.5

5.0

Preemptive <1 year 1−5 years 5−10 years 10+ years

Time on Dialysis

Per

cent

Cha

nge:

Pos

t−K

AS

Yea

r 2

vs. P

ost−

KA

S Y

ear

1

Pre−emptive listings are still increasing. Candidates with longer dialysis time decreased with subsquent increases for candidates with 1−3years.

6

A2/A2B Waiting List Eligibility by OPTN Region

0%0%

11%8%

2%2% 2%1% 1%0%

24%

13%

1%0%

7%10%

5%6% 5%4% 5%4%

0

25

50

75

100

1 2 3 4 5 6 7 8 9 10 11

OPTN Region

Per

cent

(%

) E

ligib

le

Post−KAS Year Post−KAS Year 1 Post−KAS Year 2

As of 11/30/16, 4.5% of blood type B registrations on the WL were indicated as eligible for A2/A2B kidneys.

7

Waiting List Mortality Rates by Candidate Age

0.0460.048

0.016

0.0040.0100.011

0.0070.005

0.0140.020

0.0280.032

0.0510.050

0.0720.077

0.00

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

0.10

Total 0−5 6−10 11−17 18−34 35−49 50−64 65+

Candidate Age

Dea

ths

per

patie

nt−

year

on

WL

KAS Year Post−KAS Year 1 Post−KAS Year 2

Candidates aged 18−34 and 35−49 had signficant decreases in WL mortality rates post−KAS Year 2 vs. Year 1. Thepediatric 0−5 increase is not signficant; the sample size is very small, so any death substantially raises the rate.

8

Waiting List Mortality Rates by Candidate CPRA

0.03

3

0.03

5

0.04

1

0.04

0

0.04

3

0.04

2

0.04

1

0.03

7 0.04

6

0.03

5

0.03

20.03

9

0.04

3

0.04

1

0.03

6

0.03

9

0.03

9

0.03

5

0.03

8

0.03

7

0.03

2

0.03

8 0.04

5

0.04

9

0.04

3

0.03

3

0.04

6

0.04

7

0.04

7

0.04

7

0.04

6

0.04

3

0.04

70.05

4

0.00

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

0.10

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 100Candidate CPRA

Dea

ths

per

patie

nt−

year

on

WL


Waiting list mortality rates had no significant changes post−KAS Year 2 vs. Year 1.

9

Waiting List Mortality Rates by Region

0.04

3

0.04

5

0.04

5

0.04

6 0.05

3

0.05

7

0.04

5

0.05

2

0.04

7

0.04

6

0.03

1

0.03

1 0.04

1

0.04

5

0.04

3

0.04

3

0.05

6

0.05

1

0.04

1

0.03

8

0.04

0

0.04

6

0.00

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

0.10

1 2 3 4 5 6 7 8 9 10 11

Candidate OPTN Region at Listing

Dea

ths

per

patie

nt−

year

on

WL


Waiting list mortality rates have remained virtually unchanged. Region 4 had the only significant change, decreasing post−KAS Year 2 vs. Year 1.

10

Switching Status Within 60 Days of Listing

9748

20111507

24744

7314

18311741

25783

6518

17071827

26861

0

10000

20000

30000

PRE−KAS 2014 POST−KAS 2015 POST−KAS 2016

Num

ber

of C

andi

date

s

Listing Status/Status at 60 Days ACT_ACT ACT_INACT INACT_ACT INACT_INACT

The number and percent of candidates listed as active and remaining active at 60 days post−listing has been increasing.

11

Other Noteworthy Waitlist Findings

‚ By OPTN region, the distribution of registrations added by candidatecharacteristics such as age, ethnicity, dialysis time, and CPRA have notchanged post-KAS Year 1 to post-KAS Year 2.

‚ Region 3 has a higher percent of Black than White candidates.‚ Regions 2, 4, and 11 have the highest percent of CPRA 100 candidates.

12

Deceased Donor Kidney Transplants

13

Solitary Deceased Donor Transplants Under KAS

1−Ye

ar P

ost−

KA

S Im

plem

enta

tion

0

100

200

300

400

500

600

700

800

900

1000

1100

1200

1300

Dec 31, 2014 Mar 30, 2015 Jun 30, 2015 Oct 01, 2015 Dec 31, 2015 Mar 30, 2016 Jun 30, 2016 Oct 01, 2016Month

Tran

spla

nts

Per

30

Day

s

Transplants increased 9.1% post−KAS, from 11,392 Post−KAS Year 1 to 12,433 Post−KAS Year 2, though the rise in transplants cannot be entirely attributed to KAS.

14

Geographic Distribution of Kidney Transplants

3.9%3.4%

12.7%13.0%13.5%

14.2%

9.9%9.7%

18.0%17.5%

3.7%3.8%

7.4%6.4% 6.3%6.4%

7.2%6.7%7.2%

7.8%

10.2%10.9%

0%

5%

10%

15%

20%

25%

1 2 3 4 5 6 7 8 9 10 11

OPTN Region

Post−KAS Year 1 Post−KAS Year 2

No substantial changes in any region post−KAS Year 2 vs. post−KAS Year 1.

15

Deceased Donor Transplants by Recipient Age

0.7%0.7%0.2% 0.7%0.8%0.2%

2.3%2.3%0.5%

12.0%12.8%

8.6%

26.0%27.9%

24.4%

38.8%37.2%

43.6%

19.5%18.2%

22.4%

0%

10%

20%

30%

40%

0−5 6−10 11−17 18−34 35−49 50−64 65+

Recipient Age

Waitlist (11/30/2016) Post−KAS Year1 Post−KAS Year 2

The percent of transplants to younger candidates (18−49) decreased slightly, and transplants to 50+ candidates increased slightly.

16

Transplant Rates (per Active Patient-Year) by CandidateAge

1.000.93

1.081.16

1.22

1.03

0.260.25 0.210.20 0.180.16 0.190.170.210.19

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

0−5 6−10 11−17 18−34 35−49 50−64 65+ Total

Candidate Age

Tran

spla

nts

per

patie

nt−

year

on

WL


Transplant rates were higher overall, as well as for almost every age group. The slight decrease for ages 6−10 was not significant.

17

Geographic Distribution of Pediatric Kidney Transplants

5.9%

2.9%4.1%

9.8%9.9%

7.6%

16.7%15.8%16.8%

15.0%14.7%13.2%

15.6%16.0%

21.2%

3.9%3.4%2.2%

5.6%7.4%

5.6%

10.0%7.7%7.1%

5.0%5.0%5.2%6.5%

7.7%7.6%6.1%

9.5%9.5%

0%

10%

20%

30%

40%

50%

1 2 3 4 5 6 7 8 9 10 11

OPTN Region

Pre−KAS Post−KAS Year 1 Post−KAS Year 2

Post−KAS, most regions had higher or similar percent of pediatric transplants Year 2 vs. Year 1; regions 7, 10, and 11 had a decrease in pediatric transplants, while regions 1 and 8 saw increases.

18

Rates of Receiving/Accepting Offers by Candidate Age

0

10

20

30

0−5 6−10 11−17 18−34 35−49 50−64 65+

Candidate Age

Offe

rs R

ecei

ved

per

Year

0.0

2.5

5.0

7.5

10.0

0−5 6−10 11−17 18−34 35−49 50−64 65+

Candidate Age

Per

cent

of O

ffers

Acc

epte

d


Offer rates were higher Post-KAS Year 2 vs. Post-KAS Year 1 for all age groups, and there was a drop in acceptance rates Year 2 for pediatrics age

6-10.

19

Deceased Donor Transplants by Recipient CPRA

56.4%55.6%

62.2%

8.0%7.8%8.9%

3.5%3.3%3.5% 2.6%2.5%2.6% 2.3%2.2%2.2% 2.6%2.2%2.5% 2.3%2.1%2.2% 2.3%2.3%2.2% 1.6%1.1%1.2% 1.7%1.6%1.2%2.7%2.4%1.6% 0.7%0.7%0.4% 0.8%0.7%0.6% 0.9%0.9%0.7% 1.3%1.2%0.9%

2.8%3.4%1.6%

7.6%10.0%

5.3%

0%

20%

40%

60%

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

Recipient CPRA

Waitlist (11/30/2016) Post−KAS Year 1 Post−KAS Year 2

Transplants dropped for CPRA 99−100% in the 2nd year post−KAS.

20

Transplant Rates (per Active Patient-Year) by CandidateCPRA

0.180.17 0.180.170.200.18

0.200.18 0.210.19 0.210.16

0.190.170.210.19

0.26

0.17

0.270.23

0.34

0.260.31

0.28 0.28

0.190.23

0.200.26

0.19

0.320.30 0.290.32

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

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 100Candidate CPRA

Tran

spla

nts

per

patie

nt−

year

on

WL


Recall that pre−KAS, CPRA 80−89% had the highest transplant rates, and this shifted to CPRA 99−100% post−KAS. Post−KAS Year 2, transplant rates to CPRA 100% dropped slightly, and increased for all other CPRA groups.

21

Rates of Receiving/Accepting Offers by Candidate CPRA

0

10

20

30

0 1−1920−29

30−3940−49

50−5960−69

70−7980−84

85−8990−94

95 96 97 98 99 100

Candidate CPRA

Offe

rs R

ecei

ved

per

Year

0

10

20

30

0 1−1920−29

30−3940−49

50−5960−69

70−7980−84

85−8990−94

95 96 97 98 99 100

Candidate CPRA

Per

cent

of O

ffers

Acc

epte

d


Offer rates increased for all CPRA groups except the very highly sensitized candidates.

22

CPRA 99-100% Recipient “Bolus Effect”

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%15.4%

13.4%

14.6%

12.6%

13.4%

11.7%11.2%

12.2%11.8%

12.4%11.9%

10.2%10.6%

10.1%9.7% 9.5%

9.9%9.6%

10.5%

9.7%10.0%

12.3%

10.1%9.6%

KA

S Im

plem

enta

tion

0

5

10

15

20

Feb−2014 May−2014 Aug−2014 Nov−2014 Feb−2015 May−2015 Aug−2015 Nov−2015 Feb−2016 May−2016 Aug−2016 Nov−2016 Feb−2017

Transplant Date

Per

cent

of T

rans

plan

ts to

CP

RA

99−

100%

Rec

ipie

nts

Transplants to CPRA 99−100% patients rose sharply after KAS but have tapered to around 10%.

23

Deceased Donor Transplants by Recipient Duration onDialysis

6.6%5.6%

16.9%

9.0%8.0%8.6%

44.7%

41.2%

49.4%

33.7%35.0%

20.6%

6.1%

10.2%

4.5%

0%

1,000%

2,000%

3,000%

4,000%

5,000%

Preemptive 0−1 1−5 5−10 10+

Recipient Duration on Dialysis (years)

Waitlist (11/30/2016) Post−KAS Year 1 Post−KAS Year 2

Transplants to long dialysis duration recipients decreased in the 2nd year post−KAS. Compared to pre−KAS (not shown), transplants remain higher for recipients with 5+ years of dialysis.

24

Transplant Rates (per Active Patient-Year) by CandidateTime on Dialysis

0.100.080.13

0.100.140.12

0.240.20

0.470.44

0.61

0.79

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

Preemptive 0−1 1−3 3−5 5−10 10+

Candidate Time on Dialysis (years)

Tran

spla

nts

per

patie

nt−

year

on

WL


Post−KAS Year 2, transplant rates to candidates with 10+ years of dialysis decreased significantly. All other dialysis groups increased significantly.

25

Rates of Receiving/Accepting Offers by Candidate Timeon Dialysis


0

10

20

30

40

No dialysis 0−<1 year 1−<3 years 3−<5 years 5−<10 years 10+ years


Offe

rs R

ecei

ved

per

Year

0

2

4

6

8

No dialysis 0−<1 year 1−<3 years 3−<5 years 5−<10 years 10+ years


Per

cent

of O

ffers

Acc

epte

dOffer rates decreased Post-KAS Year 2 vs. Year 1 for patients with 10+ years of dialysis. Offer acceptance rates increase as candidate dialysis time

increases. 26

High Dialysis Time Recipient “Bolus Effect”

4.3% 4.3%

6.2%

4.8% 4.6% 4.5%

5.2% 5.2% 5.2%

3.3%3.6%

4.5%

18.6%

17.1%

12.2%

11.1%

12.4%

8.9%8.3%

9.1%

7.7% 7.6% 7.5%

6.7%

6.0%

6.7%6.2%

6.8%

5.7%

6.8%

6.0%5.6%

7.2% 7.0%

4.1%

5.7%

KA

S Im

plem

enta

tion

0

5

10

15

20

Feb−2014 May−2014 Aug−2014 Nov−2014 Feb−2015 May−2015 Aug−2015 Nov−2015 Feb−2016 May−2016 Aug−2016 Nov−2016 Feb−2017

Transplant Date

Per

cent

of T

rans

plan

ts to

Rec

ipie

nts

with

10+

Yea

rs o

f Dia

lysi

s

Transplants to candidates with 10+ years of dialysis rose sharply after KAS but have tapered substantially to around 6%.

27

Deceased Donor Transplants by Recipient Ethnicity

36.7%35.3%

36.7%

34.5%

36.8%

33.3%

19.5%18.6%

19.5%

7.1%6.8%8.3%

0.9%1.3%1.0% 0.5%0.5%0.5% 0.9%0.7%0.7%0%

10%

20%

30%

White Black Hispanic Asian Native American Native Islander Multiracial

Recipient Ethnicity

Waitlist (11/30/2016) Post−KAS (1 Year) Post−KAS (Year 2)

Transplant proportions by ethnicity are reflective of waiting list percentage for most groups.

28

Transplant Rates (per Active Patient-Year) by CandidateEthnicity

0.21

0.19

0.210.210.20

0.17 0.160.15

0.230.24

0.0

0.1

0.2

0.3

0.4

White Black Hispanic Asian Other

Candidate Ethnicity

Tran

spla

nts

per

patie

nt−

year

on

WL


Transplant rates were approximately the same or higher across all ethnicity groups.

29

A2/A2B Subtype to Blood Type B Recipients

KAS Year # A2/A2B to B Transplants % of TransplantsPre-KAS 19 0.2%Post-KAS Year 1 109 1.0%Post-KAS Year 2 168 1.4%

A2/A2B to B transplants continue to slowly increase under KAS.

30

Other Noteworthy Transplant Findings

‚ Transplants involving KDPI 86-100% donor kidneys has decreased from 8.6%pre-KAS to 7.5% Year 1 and 7.7% Year 2 post-KAS

‚ Transplants involving KDPI 21-34% donor kidneys has increased from 15.7%pre-KAS to 16.0% Year 1 and 17.2% Year 2 post-KAS

‚ The percent of deceased donor kidney alone transplants receiving a repeattransplant has increased under KAS, though decreased from Year 1 to Year 2post-KAS

‚ Pre-KAS: 12.2%, Post-KAS Year 1: 15.8%, Post-KAS Year 2: 14.1%

‚ The number of dual deceased donor kidney transplants continues to remainlower post- vs. pre-KAS

‚ Pre-KAS: 0.9%, Post-KAS Year 1: 0.6%, Post-KAS Year 2: 0.5%

31

Other Noteworthy Transplant Findings

‚ Transplant percentages by ethnicity reflect waiting list percentages‚ The distribution of transplants by recipient ABO has changed little‚ The proportion of transplanted deceased donor kidneys used in multi-organ

transplants has changed little

‚ Pre-KAS: 11.2%, Post-KAS Year 1: 11.7%, Post-KAS Year 2: 11.7%‚ Less than 2% of multi-organ transplants were KDPI 86-100% in either post-KAS

year, while nearly 50% were KDPI 0-20%

‚ Longevity matching continues to be a success, with over half (56%) of EPTS0-20% adult recipients receiving KDPI 0-20% kidneys, while only 1% recieved aKDPI 86-100% kidney

32

Geographic Distribution of Kidney Transplants

18.79%

12.72%

68.49%

16.96%

12.68%

70.36%

0%

25%

50%

75%

100%

Post−KAS Year 1 Post−KAS Year 2KAS Year

Per

cent

(%

)

Share Type Local Regional National

The percent of all deceased donor kidney alone transplants going regionally or nationally (non−local) remained stable post−KAS from 31.6% post−KAS Year 1 to 29.6% post−KAS Year 2.

33

Cold Ischemic Time

1.5%1.6%

9.4%9.0%

16.3%15.4%

18.3%18.6% 18.3%18.2%

14.4%14.1%

16.0%

18.2%

3.8%4.1%

0%

5%

10%

15%

0−4 4−8 8−12 12−16 16−20 20−24 24−36 36+

Cold Ischemic Time (hours)

Per

cent


CIT 24+ hours tapered slightly in the 2nd year from 18.9% pre−KAS to 22.4% post−KAS Year 1 to 19.8% post−KAS Year 2.

34

Solitary Deceased Donor Kidney Transplant Volume byDSA

0

100

200

300

400

500

600

700

0 100 200 300 400 500 600

Post−KAS Year 1 Transplants

Pos

t−K

AS

Yea

r 2

Tran

spla

nts

Similar to pre−KAS vs. post−KAS Year 1, 36 (62%) of 58 DSAs had an increase in volume post−KAS Year 2 vs. post−KAS Year 1.

35

Solitary Deceased Donor Kidney Transplant Volume byCenter

0

50

100

150

200

250

300

350

400

0 50 100 150 200 250 300


Pos

t−K

AS

Yea

r 2

Tran

spla

nts

Of 235 programs that performed transplants post−KAS Year 1, 146 (62%) had an increase in volume post−KAS Year 2 vs. post−KAS Year 1.

36

Solitary Deceased Donor Kidney Transplant Volume byCenter

0

15

30

45

60

75

0 15 30 45 60


Pos

t−K

AS

Yea

r 2

Tran

spla

nts

Small Volume Centers: < 100 Transplants in Two Years Post−KAS

Substantial variability post−KAS Year 1 vs. Year 2 variability among small programs.

37

Deceased Donor Kidney Recovery andUtilization

38

Solitary Deceased Kidney Donors Recovered Under KAS

1−Ye

ar P

ost−

KA

S Im

plem

enta

tion

0

100

200

300

400

500

600

700

800

900

1000

Oct 31, 2014

Jan 30, 2015

Apr 30, 2015

Jul 31, 2015

Oct 31, 2015

Jan 30, 2016

Apr 30, 2016

Jul 31, 2016

Oct 31, 2016

Month

Num

ber

of K

idne

y D

onor

s R

ecov

ered

P

er 3

0 D

ays

Recovered kidney donor volume increased 9.8% post−KAS, from 8,221 Post−KAS Year 1 to 9,026 Post−KAS Year 2.

39

Kidney Discard Rate by KDPI

2.7%2.5%2.5%5.2%6.7%6.4%

19.7%18.5%17.1%

59.3%58.9%54.8%

0%

20%

40%

60%

0−20 21−34 35−85 86−100

KDPI (%)

KAS Year Pre−KAS Post−KAS Year 1 Post−KAS Year 2

The overall discard rate increased from 19.3% post−KAS Year 1 to 19.9% post−KAS Year 2. KDPI 21−34% kidneys saw a decrease in discard rate in the most recent year, while KDPI 35−85% kidneys discard rates increased again. KDPI 0−20% and 86−100% remain

fairly stable in the post−KAS era.

40

Kidney Discard Rate by KDPI

1.7%1.3%3.7%3.6% 4.7%6.1% 7.8%6.9%

11.8%10.1%

16.2%14.3%

19.8%19.8%

28.4%28.0%

41.7%40.2%

65.0%66.8%

0%

20%

40%

60%

0−10 11−20 21−30 31−40 41−50 51−60 61−70 71−80 81−90 91−100

KDPI (%)


Looking at a finer breakdown of KDPI, for the most part, as KDPI increases, discard rates increase. Discard rates for 21−30% and 91−100% KDPI kidneys decreased in the 2nd year post−KAS. Pre−KAS KDPI data presented in the 1−year report were not this granular.

41

Kidney Discard Rate by DCD vs. Brain Dead

19.5%19.1%18.6%

21.6%20.8%

17.6%

0%

5%

10%

15%

20%

25%

Brain Dead DCD

Brain Dead vs. DCD)

KAS Year Pre−KAS Post−KAS Year 1 Post−KAS Year 2

While the discard rate continues to increase overall, the increase was larger for DCD donor kidneys vs. Brain Dead donor kidneys.

42

Kidney Discard Reasons

28.5

%

33.5

%

39.2

%

28.9

%

12.1

%

15.2

%

0%

10%

20%

30%

40%

50%

Biopsy

findin

gs

No re

cipien

t loca

ted

− lis

t exh

auste

d

Other

, spe

cify

Anato

mica

l abn

orm

alitie

s

Poor o

rgan

func

tion

Diseas

ed o

rgan

Vascu

lar d

amag

e

Organ

trau

ma

Too

old o

n ice

Donor

Med

ical h

istor

y

Recipi

ent d

eter

mine

d to

be

unsu

itable

for T

X in O

R

Positiv

e Hep

atitis

Urete

ral d

amag

e

Too

old o

n pu

mp

Organ

not

as d

escr

ibed

War

m is

chem

ic tim

e to

o lon

g

Donor

socia

l hist

ory

Infec

tion

Positiv

e HIV

Discard Reasons


Reasons for discard are mostly similar post−KAS Year 2 vs. Year 1. However, there was an obvious increase in list exhaustion and a subsequent decrease in biopsy findings and other.

43

Percent of Offers Accepted Non-Locally Not Going toAcceptor

27.6%25.7%

0%

10%

20%

30%

40%

50%


Slight decrease in number of non−local acceptances (size of bubble; 4,923 to 4,896) and percent of kidneys not transplanted tothese acceptors (27.6%o 25.7%) post−KAS Year 1 to Year 2. For reference, pre−KAS was 31.9%. Seven programs accounted for 61% of

cases Year 1 and these same programs accounted for 54% of cases Year 2.

Overall, there's been an increase in transplants going to the acceptor.

44

Percent of Offers Accepted Non-Locally Not Going toAcceptor by CPRA

32.7% 30.0%

0%

10%

20%

30%

40%

50%


CPRA 0−98%

CPRA 0−98%: increase in number of non−local acceptances (size of bubble; 3,268 to 3,587) but decrease in percent of kidneys not transplanted to these acceptors (32.7% to 30.0%) post−KAS Year 1 to Year 2. For reference, pre−KAS was 32.0%.

17.7%14.1%

0%

10%

20%

30%

40%

50%


CPRA 99−100%

CPRA 99−100%: decrease in number of non−local acceptances (size of bubble; 1,655 to 1,309) and percent of kidneys not transplanted to these acceptors (17.7% to 14.1%) post−KAS Year 1 to Year 2. For reference, pre−KAS was 29.3%.

45

Percent of Offers Accepted Non-Locally Not Transplantedto the Acceptor that were Discarded

36.1%34.0%

0%

25%

50%

75%

100%


Just over a third of kidneys accepted but not transplatned to the accepting patient were discarded both years post−KAS; the remaining two−thirds were transplanted into another recipient. This holds steady versus pre−KAS.

46

Other Noteworthy Utilization Findings

‚ Similarly to pre-KAS vs. post-KAS Year 1, the distribution of donors recoveredby KDPI has remained similar post-KAS Year 2.

‚ The percent of discarded kidneys that were pumped increased from 24.7%post-KAS Year 1 to 28.4% post-KAS Year 2

47

Recipient Outcomes

48

Delayed Graft Function (DGF) Rates

24.4%

29.6%

27.7%

0%

10%

20%

30%

Pre−KAS Post−KAS Year 1 Post−KAS Year 2KAS Year

Per

cent

Del

ayed

Gra

ft F

unct

ion

(DG

F)

The percentage of recipients requiring dialysis within the first week after transplant decreased from 29.6% post−KAS Year 1 to 27.7% post−KAS Year 2, but remains higher than pre−KAS. The decrease was significant (p = 0.0010).

49

Characteristics of Recipients with DGF

12.24 14.71

61.86

11.19 11.5015.00

62.88

10.61 12.42 14.38

63.26

9.94

Pre−KAS: 12/4/13 − 12/3/14 Post−KAS Year 1: 12/4/14 − 12/3/15 Post−KAS Year 2: 12/4/15 − 12/3/16

0−20% 21−34% 35−85% 86−100% 0−20% 21−34% 35−85% 86−100% 0−20% 21−34% 35−85% 86−100%

0

25

50

75

100

KDPI

Per

cent

(%

)

The majority of recipients with DGF received KDPI 35−85% kidneys.

50

Characteristics of Recipients with DGF

61.67

23.31

8.783.64 2.59

57.55

21.49

4.65 3.17

13.13

58.67

22.33

5.823.07

10.11

Pre−KAS: 12/4/13 − 12/3/14 Post−KAS Year 1: 12/4/14 − 12/3/15 Post−KAS Year 2: 12/4/15 − 12/3/16

0 1−79 80−94 95−98 99−100 0 1−79 80−94 95−98 99−100 0 1−79 80−94 95−98 99−100

0

25

50

75

100

CPRA

Per

cent

(%

)

Of recipients with DGF, there was an increase with KAS of CPRA 99−100% patients, but this dropped some in Year 2. The majority of recipients with DGF were not highly sensitized.

51

Other Noteworthy DGF Findings‚ DGF rates decreased for all levels of KDPI, CPRA, and dialysis time.‚ The DGF rate increases markedly as time on dialysis increases. Under KAS,

many more patients with higher dialysis times are being transplanted.‚ Similarly, DGF rates markedly increase as CIT increases.‚ DGF rates decreased regardless of share type or pumping status.‚ Among those with DGF:

‚ There was little change in most donor, recipient, or transplant characteristicsexamined pre-KAS to post-KAS Year 2

§ Donor terminal creatinine remained stable at 1.00 across all three years.

‚ The majority of those with DGF were KDPI 35-85%, Brain Dead, 5-<10 yearsdialysis, CPRA 0%, Diabetic or Hypertensive Nephrosclerotic, 12-24 hours of CIT,or local.

§ Recipents with DGF were approximately 50% each for kidneys pumped vs. notpumped.

52

Patient Survival - Overall

p−value: 0.0026

80%

85%

90%

95%

100%

0 30 60 90 120 150 180 210 240 270 300 330 360Time Post−Transplant (Days)

Pat

ient

Sur

viva

l (%

)

KAS Year Pre−KAS Post−KAS

53

Graft Survival - Overall

p−value: 0.0727

80%

85%

90%

95%

100%

0 30 60 90 120 150 180 210 240 270 300 330 360Time Post−Transplant (Days)

Gra

ft S

urvi

val (

%)

KAS Year Pre−KAS Post−KAS

54

Survival - KDPI > 85%KAS Year Pre−KAS Post−KAS Year 1

p−value: 0.5200

80%

85%

90%

95%

100%

0 30 60 90 120

150

180

210

240

270

300

330

360

Time Post−Transplant (Days)

Pat

ient

Sur

viva

l (%

)

p−value: 0.5143

80%

85%

90%

95%

100%

0 30 60 90 120

150

180

210

240

270

300

330

360


Gra

ft S

urvi

val (

%)

55

Survival - CPRA 99-100%KAS Year Pre−KAS Post−KAS Year 1

p−value: 0.2487

80%

85%

90%

95%

100%

0 30 60 90 120

150

180

210

240

270

300

330

360


Pat

ient

Sur

viva

l (%

)

p−value: 0.6614

80%

85%

90%

95%

100%

0 30 60 90 120

150

180

210

240

270

300

330

360


Gra

ft S

urvi

val (

%)

56

Survival - Dialysis 10+ YearsKAS Year Pre−KAS Post−KAS Year 1

p−value: 0.1633

80%

85%

90%

95%

100%

0 30 60 90 120

150

180

210

240

270

300

330

360


Pat

ient

Sur

viva

l (%

)

p−value: 0.3468

80%

85%

90%

95%

100%

0 30 60 90 120

150

180

210

240

270

300

330

360


Gra

ft S

urvi

val (

%)

57

Survival - PediatricsKAS Year Pre−KAS Post−KAS Year 1

p−value: 0.9999

80%

85%

90%

95%

100%

0 30 60 90 120

150

180

210

240

270

300

330

360


Pat

ient

Sur

viva

l (%

)

p−value: 0.0426

80%

85%

90%

95%

100%

0 30 60 90 120

150

180

210

240

270

300

330

360


Gra

ft S

urvi

val (

%)

58

Survival - CIT 36+ HoursKAS Year Pre−KAS Post−KAS

p−value: 0.2162

80%

85%

90%

95%

100%

0 30 60 90 120

150

180

210

240

270

300

330

360


Pat

ient

Sur

viva

l (%

)

p−value: 0.0292

80%

85%

90%

95%

100%

0 30 60 90 120

150

180

210

240

270

300

330

360


Gra

ft S

urvi

val (

%)

This drop may taper at two years given that CIT is decreasing as centers are adjusting to the system.

59

Relisting Rates Within One Year of Transplant

1.64%1.38%

p = 0.1009

0.0

2.5

5.0

7.5

10.0

Pre−KAS Post−KAS

Per

cent

(%

)

Relisting rates within one year of transplant decreased from 1.64% to 1.38%, but this was not a significant change (p = 0.1009).

60

Other Noteworthy Outcomes Findings

‚ One-year Serum Creatinine increase was significant (1.27 to 1.30) post-KASYear 1 to Year 2.

‚ One-year eGFR increase was not significant (61.0 to 61.1) post-KAS Year 1 toYear 2.

61

Thank You!

62

UNOS Research DepartmentData Quality TeamBrooke Chenault, CCRAJessie Maker, MSTammy SneadTenisha AtobrahPenny BrockSharon GravesClay McDonaldJo Smith

Data ScientistsHarris McGeheeSubhash Jaini, MS

Project LeadersAlex GarzaHeather Neil

Data Analytics TeamEric BeesonTim BakerJude Maghirang, MSYulin ChengJohn Beck, MSMESherri WilliamsDenise TrippAnn Harper, MPHJaime WilliamsonWes RossonAlice Toll

Scientists and AnalystsWida Cherikh, PhDJohn Rosendale, MSDarren Stewart, MSAmber Wilk, PhDJennifer Wainright, PhDAnna Kucheryavaya, MSMarissa Clark, MSMike Curry, MSRead Urban, MPHAmanda Robinson, MSVictoria Garcia, MPH

LeadershipRyan Ehrensberger, PhD, FACHEDavid Klassen, MDBob Carrico, PhDSarah TarantoCherri Taylor

63

Documents

The Kidney Allocation System (KAS) - The First Two Years · The Kidney Allocation System (KAS) The First Two Years Amber R. Wilk, PhD John Beck Anna Y. Kucheryavaya, MS United Network