FIRST YEAR’S EXPERIENCE WITH THE NEW EXPANDED CRITERIA DONOR KIDNEY ALLOCATION SYSTEM.

Abstract

P103 A new Organ Procurement and Transplantation Network (OPTN) policy to expedite the placement of Expanded Criteria Donor (ECD) deceased donor kidneys was implemented on October 30, 2002. The rationale for this system was to increase the recovery and utilization of these kidneys by encouraging a more structured candidate listing process and using an allocation system that would encourage Organ Procurement Organizations (OPOs) to pursue recovery from ECDs. We will present OPTN/UNOS data from the initial 12 month experience with the allocation system. Methods: ECDs were previously defined as those having a 70% increased relative risk (RR) of graft failure as compared to an ideal donor. This definition was adapted by the OPTN and includes all donors over age 60 and those 50-59 years who have two or more of: a history of hypertension, death from a CVA, or a serum creatinine > 1.5 mg/dl. A separate list for ECD candidates was established and an expedited placement process was initiated where kidneys are allocated first to zero antigen mismatch ECD candidates and next, to ECD candidates on the basis of waiting time only. Programs were encouraged to list preferentially those candidates at greater risk of death on the wait list: those over age 60, diabetics over age 40, and candidates with vascular access failure. The donor was classified as a Standard (SCD) or ECD at the time of the match run. The initial 12 month experience (11/02 – 10/03) was compared to the previous 12 month period prior to implementation of the allocation system (11/01 – 10/02). Results: A snapshot of ECD candidate listings and program acceptance rates indicated a wide variation in transplant programs participating in the ECD allocation system (0 - 100% candidate listings and 0 – 92% kidney offer acceptance). Following implementation, the number of ECDs increased from 1024 to 1062, kidneys recovered from 2030 to 2106, and kidneys transplanted from 1288 to 1321. The discard rate increased slightly from 36.6% to 37.3%. The primary reason for discard was biopsy findings. Local ECD kidneys had higher acceptance rates (32%) compared to imported SCD kidneys (20.5%). More ECD kidneys were maintained by machine preservation (26.9%) versus the prior period (21.2%). Delayed graft function rate (DGF) declined minimally from 35.6% to 34.4% but was significantly lower (p<0.001) in the machine perfused (23.3%) compared to cold storage (38.6%) during the period of ECD implementation. OPOs recovering and utilizing more ECD kidneys had more local programs transplanting higher percentages of their grafts from ECDs. Conclusion: While previous OPTN/UNOS allocation policies have addressed issues of medical urgency, equity, and outcomes, the ECD allocation system signalled a new era in policy development: an effort designed primarily to increase organ utilization. This initial analysis demonstrates small, but positive, increases in utilization of ECDs since policy implementation.