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
Lung and Heart-Lung Registrations
1800
1600
LAS = 0
1400
LAS > 0
1200
1269
1270
1256
1238
1222
1202
1191
1181
1182
1162
1000
800
600
400
408
369
200
349
335
331
318
310
304
289
281
5/18
5/25
6/1
6/8
6/15
6/22
6/29
7/6
0
5/4
5/11
N=1667
N=1443
Active Lung And Heart-Lung Registrations (12+)
On July 6, 2005, By Region
Lung and Heart-Lung Registrations
275
240
250
225
210
208
200
175
150
150
125
136
121
112
106
100
85
75
53
50
22
25
0
1
2
3
4
5
6
Region
7
8
9
10
11
LAS for Active Lung And Heart-Lung
Registrations (12+) With Nonzero Scores
On July 6, 2005, by Diagnosis Group
Age Group
Adult (18+)
Pediatric
(12-17)
Diagnosis
Group
N
Median
Score
ALL
1104
33.12
A (COPD)
506
32.16
B (PPH)
115
32.39
C (CF)
163
34.21
D (IPF)
320
36.26
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
Percent of Transplants
By Diagnosis group
60
50
40
30
20
10
0
A (COPD)
B (PPH)
5/5/2004-7/5/04
C (CF)
D (IPF)
5/5/2005-7/5/2005
Lung Utilization
May 4, 2004 – June
3, 2004
Donors
Deceased
donors
Deceased
donor
lungs
Donors with at
least 1 lung
transplanted
Lungs
(2*donors)
Lungs
transplanted
May 4, 2005 – June
3, 2005
N
% of
donors
N
% of
donors
606
100.0
671
100.0
82
13.5
113
16.8
N
% of
lungs
N
% of
lungs
1212
100.0
1342
100.0
149
12.3
205
15.3
Percent of Lungs Transplanted*
May 4, 2005 – June 3, 2005
Percent of Lungs Transplanted
100
80
60
40
20
0
1
2
3
4
5
6
Region
* Percent = # Lungs transplanted / donors*2
7
8
9
10
11
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:
5/7/02-5/6/03
N = 3,236
 Post-policy period: 5/7/03-5/6/04
N = 3,001
Percent of Transplants
Non-Zero MM Transplants
by Policy Period and Ethnicity
100
P=0.002
80
60
49.5 44.6
40
32.3
35.6
20
11.8 12
4 4.9
2.4 2.9
Asian
Other
0
White
Black
Hispanic
Pre-Policy
Post-Policy
Percent of Transplants
Non-Zero MM Transplants
by Policy Period and HLA DR MM
100
P<0.001
80
60
48.2
54.7
40
28.6
23.2
20
31
14.3
0
0 DR MM
1 DR MM
Pre-Policy
Post-Policy
2 DR MM
Percent of Transplants
Non-Zero MM Transplants
by Policy Period and HLA MM
100
P<0.001
80
60
40
20
25.6
14.7
12.3
3.3 1.1
36.2
31.8
27.3
19.8
11.7 12.2
4.1
0
1 MM
2 MM
3 MM
Pre-Policy
4 MM
5 MM
Post-Policy
6 MM
Percent of Transplants
Non-Zero MM Transplants
by Policy Period and Peak PRA (%)
100
79
80
P<0.001
74
60
40
20
3.7 3.8
10.4 12
7.3 9.9
21% - 79%
80%+
0
Not Reported
0% - 20%
Pre-Policy
Post-Policy
Non-Zero MM Transplants
by Policy Period and Wait Time
Percent of Transplants
100
P<0.001
80
60
40
37.9
30.3
23.4 23.3
26.4
31.7
12.4 14.7
20
0
<=1 yr
1- 2 yrs
Pre-Policy
2 - 4 yrs
Post-Policy 1
>4 yrs
Kaplan-Meier Graft Survival
by Policy Period
100
P=0.20
Survival (%)
90
80
70
60
50
0
3
6
Pre-Policy
9
Post-Policy
12
15
Summary
Compared with pre-policy period:





More minority candidates received a nonzero 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 1B
Regional – Status 1A, Status 1B
Local – MELD/PELD > 15
Regional – MELD/PELD > 15
Local – MELD/PELD < 15
Regional – MELD/PELD < 15
National – Status 1A, Status 1B, MELD/PELD
Previously:





Local – Status 1A, Status 1B
Regional – Status 1A, Status 1B
Local – MELD/PELD
Regional – MELD/PELD
National – Status 1A, Status 1B, MELD/PELD
Adult Deceased Donor Liver Transplants
Pre-Policy Period: 1/12/04 – 5/11/04
Number of Transplants
300
250
200
150
100
50
0
1
2
3
4
5
6
7
8
9
Region
MELD < 15
MELD >= 15
Status 1
10
11
Adult Deceased Donor Liver Transplants
Post-Policy Period: 1/12/05 – 5/11/05
Number of Transplants
300
250
200
150
100
50
0
1
2
3
4
5
6
7
8
9
Region
MELD < 15
MELD >= 15
Status 1
10
11
Adults Removed for Death/Too Sick from
Liver Waiting List
Pre-Policy Period: 1/12/04 – 5/11/04
Number of Candidates
120
100
80
60
40
20
0
1
2
3
4
5
6
7
8
9
Region
MELD < 15
MELD >= 15
Status 1
10
11
Adults Removed for Death/Too Sick from
Liver Waiting List
Post-Policy Period: 1/12/05 – 5/11/05
Number of Candidates
120
100
80
60
40
20
0
1
2
3
4
5
6
7
8
9
Region
MELD < 15
MELD >= 15
Status 1
10
11
Death Rates per 1000 Patient Days
Liver Candidates on the Waiting List
During 9/12/04 - 5/11/05
By Age at Listing and Policy Period
Death Rate per 1000 patient days
1.2
0.8
0.54
0.45
0.43
0.4
0.15
0.14
0
0 - 11
9/12/04 - 1/11/05
12 - 17
1/12/05 - 5/11/05
18 +
0.4
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 Donors
by Region of Recovery
Number of Transplants
2003 - 2004
2000
1800
1600
1400
1200
1000
800
600
400
200
0
1
2
3
4
5
6
7
Region of Recovery
Local
Non-Local
8
9
10
11
Kidney Transplants from Adult Donors
by Region of Recovery
2003 - 2004
Number of Transplants
3000
2500
2000
1500
1000
500
0
1
2
3
4
5
6
7
8
9
10
11
Region of Recovery
Local
Non-Local, No Local Refusals
Non-Local, Locally Refused
Kidney Transplants from Adult Donors
by Region of Recovery
Number of Transplants
2003 - 2004
3000
2500
2000
1500
1000
500
0
1
2
3
4
5
6
7
8
9
10
Region of Recovery
Local
No Local Refusal, Tx Out of Region
Locally Refused, Tx Out of Region
No Local Refusal, Tx in Region
Locally Refused, Tx in Region
11
Kidney Transplant* Graft Survival
2003-2004
Survival Rate (%)
100
80
P<0.001
60
40
20
0
0
Local
3
6
Months Post Transplant
Non-Local, No Local Refusal
9
12
Non-Local, Locally Refused
* Adult donors only, excluding multiorgan and repeat transplants.
Heart Transplants from Adult Donors
by Region of Recovery
2003 - 2004
Number of Transplants
450
400
350
300
250
200
150
100
50
0
1
2
3
4
5
6
7
Region of Recovery
Local
Non-Local
8
9
10
11
Heart Transplants from Adult Donors
by Region of Recovery
2003 - 2004
Number of Transplants
600
500
400
300
200
100
0
1
2
3
4
5
6
7
8
9
10
11
Region of Recovery
Local
Non-Local, No Local Refusals
Non-Local, Locally Refused
Heart Transplants from Adult Donors
by Region of Recovery
Number of Transplants
2003 - 2004
600
500
400
300
200
100
0
1
2
3
4
5
6
7
8
9
10
Region of Recovery
Local
No Local Refusal, Tx Out of Region
Locally Refused, Tx Out of Region
No Local Refusal, Tx in Region
Locally Refused, Tx in Region
11
Heart Transplant* Patient Survival
2003-2004
Survival Rate (%)
100
80
P=0.2
60
40
20
0
0
Local
3
6
Months Post Transplant
Non-Local, No Local Refusal
9
12
Non-Local, Locally Refused
* Adult donors only, excluding multiorgan and repeat transplants.
Liver Transplants from Adult Donors by
Region of Recovery
2003 - 2004
Number of Transplants
1200
1000
800
600
400
200
0
1
2
3
4
5
6
7
Region of Recovery
Local
Non-Local
8
9
10
11
Liver Transplants from Adult Donors by
Region of Recovery
2003 - 2004
Number of Transplants
1800
1600
1400
1200
1000
800
600
400
200
0
1
2
3
4
5
6
7
8
9
10
11
Region
Local
Non-Local, No Local Refusals
Non-Local, Locally Refused
Liver Transplants from Adult Donors
by Region of Recovery
Number of Transplants
2003 - 2004
1800
1600
1400
1200
1000
800
600
400
200
0
1
2
3
4
5
6
7
8
9
10
Region of Recovery
Local
No Local Refusal, Tx Out of Region
Locally Refused, Tx Out of Region
No Local Refusal, Tx in Region
Locally Refused, Tx in Region
11
Liver Transplant* Graft Survival
2003-2004
Survival Rate (%)
100
80
P=0.007
60
40
20
0
0
Local
3
6
Months Post Transplant
Non-Local, No Local Refusal
9
12
Non-Local, Locally Refused
* Adult donors only, excluding multiorgan and repeat transplants.
Lung Transplants from Adult Donors
by Region of Recovery
Number of Transplants
2003 - 2004
200
180
160
140
120
100
80
60
40
20
0
1
2
3
4
5
6
7
Region of Recovery
Local
Non-Local
8
9
10
11
Lung Transplants from Adult Donors
by Region of Recovery
2003 - 2004
Number of Transplants
350
300
250
200
150
100
50
0
1
2
3
4
5
6
7
8
9
10
11
Region of Recovery
Local
Non-Local, No Local Refusals
Non-Local, Locally Refused
Lung Transplants from Adult Donors
by Region of Recovery
Number of Transplants
2003 - 2004
350
300
250
200
150
100
50
0
1
2
3
4
5
6
7
8
9
10
Region of Recovery
Local
No Local Refusal, Tx Out of Region
Locally Refused, Tx Out of Region
No Local Refusal, Tx in Region
Locally Refused, Tx in Region
11
Lung Transplant* Patient Survival
2003-2004
Survival Rate (%)
100
80
P=0.17
60
40
20
0
0
Local
3
6
Months Post Transplant
Non-Local, No Local Refusal
9
12
Non-Local, Locally Refused
* Adult donors only, excluding multiorgan and repeat transplants.
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
Monthly National Donation Rates
700
Organ Donors
650
600
Collaborative
Starts Here
550
500
450
400
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1999
2000
2001
2002
2003
2004
2005
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
Organs Txed

Increase the number of deceased donor
organs transplanted each year until 42,800
are transplanted in 2013
50000
40000
30000
20000
10000
0
1990
1995
2000
2005
Year
Actual
PART Goals
2010
2015
HRSA’s PART GOALS
# Non-DCD

Increase the number of non-DCD donors
each year until 9251 is achieved in 2013
10000
8000
6000
4000
2000
0
1990
1995
2000 2005
Year
Actual
2010
PART Goals
2015
HRSA’s PART GOALS

Increase the number of DCD donors each
year until 2018 is achieved in 2013
2500
# DCD
2000
1500
1000
500
0
1993
1998
2003
2008
Year
Actual
PART Goals
2013
HRSA’s PART GOALS
Avg. Tx/Donor

Increase the average number of organs
transplanted per non-DCD donors each year by
0.080 to reach 4.0 in 2013
4.1
3.9
3.7
3.5
3.3
3.1
2.9
2.7
2.5
1990
1995
2000
2005
Year
Actual
PART Goals
2010
2015
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

Avg. Tx/Donor
3.5
3
2.5
2
1.5
1993
1998
2003
2008
Year
Actual
PART Goals
2013
HRSA’s PART GOALS
LY Gained

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
10000
8000
6000
4000
2000
0
2002
121 % Increase
2004
2006
2008
Year
2010
2012
2014
HRSA’s PART GOALS
Avg LY Gained

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 lifeyears gained per transplant is achieved in 2013
0.44
0.43
0.42
0.41
0.4
0.39
2000
8.7 % Increase
2002
2004
2006
2008
Year
2010
2012
2014
Transplants from DCD Donors
July, 2004 – June, 2005
Number of Transplants
700
651
600
500
400
300
236
200
100
22
9
4
KidneyPancreas
Lung
Pancreas
0
Kidney
Liver
DCD Kidney Transplants
July, 2003 – June, 2005
Number of Transplants
140
120
100
80
60
40
20
0
1
2
3
4
5
6
7
8
9
Region
7/1/2003-6/30/2004
7/1/2004-6/30/2005
10
11
DCD Kidney-Pancreas Transplants
July, 2003 – June, 2005
Number of Transplants
14
12
10
8
6
4
2
0
1
2
3
4
5
6
7
8
9
Region
7/1/2003-6/30/2004
7/1/2004-6/30/2005
10
11
DCD Liver Transplants
Number of Transplants
July, 2003 – June, 2005
50
45
40
35
30
25
20
15
10
5
0
1
2
3
4
5
6
7
8
9
Region
7/1/2003-6/30/2004
7/1/2004-6/30/2005
10
11
DCD Lung Transplants
July, 2003 – June, 2005
Number of Transplants
8
7
6
5
4
3
2
1
0
1
2
3
4
5
6
7
8
9
Region
7/1/2003-6/30/2004
7/1/2004-6/30/2005
10
11
Transplants from ECD Donors
July, 2004 – June, 2005
1,395
1,472
1400
1200
1000
800
600
400
Pa
nc
re
as
Lu
ng
1
Li
ve
r
K
P
ne
y
0
107
7
K
id
1
60
H
ea
rt
200
H
L
Number of Transplants
1600
ECD Kidney Transplants
July, 2003 – June, 2005
Kidney Transplants
300
250
200
150
100
50
0
1
2
3
4
5
6
7
8
9
Region
7/1/2003-6/30/2004
7/1/2004-6/30/2005
10
11
Kidney Transplant Graft Survival
2000-2003
U.S.
Survival Rate (%)
100
80
60
40
20
0
0
1
2
Years Post Transplant
SCD
DCD
ECD
3
Liver Transplant Graft Survival
2000 - 2003
U.S.
Survival Rate (%)
100
80
60
40
20
0
0
1
2
Years Post Transplant
SCD
DCD
ECD
3
Ja
n0
M 3
ar
0
M 3
ay
03
Ju
l0
Se 3
p0
No 3
v0
3
Ja
n0
M 4
ar
0
M 4
ay
04
Ju
l0
Se 4
p0
No 4
v0
4
Ja
n0
M 5
ar
05
M
ay
05
Number of Donors
DCD Donors by Month
2003 – June, 2005
60
50
40
30
20
10
0
Ja
n0
M 3
ar
0
M 3
ay
03
Ju
l0
Se 3
p0
No 3
v0
3
Ja
n0
M 4
ar
0
M 4
ay
04
Ju
l0
Se 4
p0
No 4
v0
4
Ja
n0
M 5
ar
05
M
ay
05
Number of Donors
ECD Donors by Month
2003 – June, 2005
200
180
160
140
120
100
80
60
40
20
0
Organs Recovered Per Donor by Donor Type
Organs Recovered per Donor
1995 – June, 2005
4.5
3.9
4.0
3.5
3.0
2.8
2.5
2.6
2.0
1.5
1.0
0.5
0.0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Standard
ECD
DCD
Organs Transplanted per Donor
Organs Transplanted Per Donor by Donor Type
1995 – June, 2005
4.0
3.6
3.5
3.0
2.5
2.0
2.0
1.8
1.5
1.0
0.5
0.0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Standard
ECD
DCD