The New Kidney Allocation System (KAS):
The First Year
Prepared for
OPTN Kidney Transplantation Committee
April 18, 2016
Darren Stewart, MS
John Beck, MSME
Anna Kucheryavaya, MS
UNOS Research Department
Slideset last modified: 04/29/16
1
Background

KAS implemented Dec 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
Background

Performance tracked monthly through June (“out of the gate” reports)

Six month report completed Sep 2015

One-year analysis now completed


Pre-KAS period: Dec 4, 2013 – Dec 3, 2014 (12 months)
Post-KAS period: Dec 4, 2014 – Dec 3, 2015 (12 months)

New: Six month graft and patient survival rates
New: Recipient serum creatinine at six months

New: Waiting list mortality rates

Background

Full, detailed report available to the committee or upon request.
Kidney waiting list trends
5
Trends in the kidney waiting list
Pre/Post-KAS Growth in the Kidney Waiting List
Jan 1, 2014 through Dec 31, 2015
120000
5,000
109,708
Kidney registrations
108,850
101,856
Kidney candidates
100,916
106,549
100000
99,222
2,917.7
60000
3,372.6
3,240.0
3,281.0
3,121.0
(pre‐KAS mean)
3,000
2,721.3
Registrations added (per 30 days)
2,743.0
2,000
40000
20000
0
1/31/14
5/11/14
8/19/14
Registrations Added (per 30 days)
80000
12/4: KAS Implementation
Total Size of the Kidney Waitlist (N)
4,000
1,000
0
11/27/14
3/7/15
6/15/15
9/23/15
1/1/16
Date


The size of the kidney waiting list has decreased slightly post-KAS.
3.5% fewer new kidney registrations added post-KAS.
Table I.1a Table I.3a
Changes in listing patterns
6.0%
4.9%
Pre vs post‐KAS % change in registrations added
4.0%
1.8%
0.3%
0.0%
‐2.0%
Overall change: ‐3.5%
‐4.0%
‐6.0%
‐6.0%
‐8.0%
‐10.0%
‐10.6%
‐12.0%
Preemptive
<1 year
1‐5 years 5‐10 years
10+ years
Time on dialysis
Pre‐KAS: 12/4/13‐12/3/14
Post‐KAS: 12/4/14‐12/3/15


Preemptive listings have increased
Sharp drops in listings of candidates with short dialysis times
Table I.3a
Trends in the kidney waiting list
Comparing 3 month-end “snapshots” by candidate CPRA and dialysis duration
80,000
11/30/2014
5/31/2015
60,000
12/3/2015
70,000
11/30/2014
5/31/2015
12/3/2015
50,000
60,000
40,000
50,000
40,000
30,000
30,000
20,000
20,000
9,148 8,443 8,061
10,000
0
10,000
5,740 5,204 4,961
0
0%
1‐79%
80‐94%
Candidate CPRA


95‐98%
99‐100%
Preemptive
<1 year
1‐5 years
5‐10 years
10+ years
Candidate Duration on Dialysis
The distribution of registrations on the waiting list by most factors (age,
race/ethnicity, diagnosis) has changed little.
Moderate changes observed by CPRA and dialysis duration.
Table I.2a
Trends in the kidney waiting list
Month‐end “snapshots”
100%
90%
70%
60%
61.0%
60.6%
50%
40%
12/4: KAS Implementation
Percent of Kidney Registrations
% of Registrations in Active Status
80%
30%
20%
10%
0%
12/31/13
2/19/14
4/10/14
5/30/14
7/19/14
9/7/14
10/27/14
12/16/14
2/4/15
3/26/15
5/15/15
Date

The % of registrations on the kidney waiting list in active status has
remained relatively constant at about 61%.
Table I.1a
Waiting list mortality rates
Pre‐KAS: 12/4/13‐12/3/14
Post‐KAS: 12/4/14‐12/3/15

Waiting list mortality rates have remained virtually unchanged.

(Pediatric drop not statistically significant)
Table I.4a
Deceased donor kidney
transplants
11
Solitary deceased donor transplants under KAS
Pre vs. post-KAS trends
Over time (per 30 days)
In total (per year)
15000
1200
1078.1
853.5
800
600
400
200
0
926.1
11,397
10,901
916.4
Number of transplants
886.5
KAS implementation
Transplants per 30 days
1000
10000
4.6%↑
5000
0
Pre‐KAS (12/4/13 ‐ 12/3/14)


Transplant volume increased 4.6%.
Increase from 896.0 to 936.7 per month.
Post‐KAS (12/4/14 ‐ 12/3/15)
Table II.1a
Who’s getting transplanted under KAS?
Percentage of Deceased Donor Kidney Transplants by Recipient Age
50%
Waitlist (11/30/2014)
Pre‐KAS (1 year)
Post‐KAS (1 year)
43.0%
39.9%
37.2%
27.9%
25.5%
24.1%
25%
22.9%
20.9%
18.1%
12.8%
9.6%
8.8%
4.2% 3.9%
0.9%
0%
0‐17
18‐34
35‐49
50‐64
65+
Recipient age

More young candidates (18-49) are receiving kidney transplants.

Transplants to pediatrics rebounded in 2nd six months
Transplant rates (per active patient-year) by
candidate age
1.2
Pre‐KAS
1.11
Post‐KAS
1.03
1
0.8
0.6
0.4
0.25
0.16
0.2
0.16
0.20
0.17
0.16
0.21
0.17
0
<18
18‐34
35‐49
50‐64
65+
Candidate age


Pediatric transplant rate fell slightly. Difference is not statistically
significant. Rate is still 5 times higher than for adults.
Transplant rate increase for 18-34 and 35-49, decreased for older patients.
Table II.12
Geographic distribution of pediatric kidney transplants
1-Yr Pre-KAS
1-Yr Post-KAS
50%
40%
30%
21.2%
20%
16.9%
14.7%
13.2%
16.0%
9.9%
10%
7.6%
4.1%
0%
15.8%
1
3.4%
2.2%
2.9%
2
3
4
5
6
7.5%
5.6%
7.1%7.7%
7
8
5.2% 5.0%
9
7.6% 7.7%
10
9.5%
9.5%
11
Region

Most regions had higher or similar percent of
pediatric transplants except for Region 1 or 5.
15
Rates of receiving and accepting offers by
candidate age
Offers received
Acceptance rates
Pre‐KAS
20
19.0
17.0
16.6
15
Post‐KAS
7
23.2
21.1
21.6
18.5
19.0
16.0
14.3
10
5
0
6
% of offers accepted
Offers received per year
25
6.53
Pre‐KAS
6.23
Post‐KAS
5
4
3
1.6
2
1.19
1
1.18
1.11
18‐34
35‐49
0.99
1.01
0.86
0.78
50‐64
65+
0
<18
18‐34
35‐49
Candidate age


50‐64
65+
<18
Candidate age
Offer rates dropped post-KAS for pediatrics, but acceptance rates remained
relatively high. Donor quality increased for pediatric offers (avg KDPI↓).
Offer acceptance rates dropped for older patients and increased for younger
adults, most likely due to organ quality (KDPI) differences.
Table II.13
Table III.5
Who’s getting transplanted under KAS?
Percentage of Deceased Donor Kidney Transplants by Recipient CPRA
75%
61.8%
60.0%
56.0%
Waitlist (11/30/2014)
Pre‐KAS (1 year)
Post‐KAS (1 year)
50%
22.5% 24.0%
22.0%
25%
13.0%
10.0%
4.2%
5.1%
8.3%
3.1% 3.5% 3.5%
2.5%
0%
0
1‐79
80‐94
95‐98
99‐100
Recipient CPRA

Transplants increased sharply for CPRA 99-100% patients but have tapered during
the 2nd six months.

Pre-KAS 12.2% of recipients had a prior transplant; this rose to 15.8% of transplants.
Transplant rates (per active patient-year) by
candidate CPRA
0.8
Pre‐KAS
0.6
0.57
0.48
0.4
0.33
0.25
0.2
0.18
0.19
0.20
0.19
0.19
0.18
0.15
0.22
0.20
0.15
0.13
0.10
0.03
0
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
Candidate CPRA


Pre-KAS, candidates with CPRA just over 80% had a marked advantage in access
to transplantation.
CPRA 99-100% patients had very little access.
Table II.12
Transplant rates (per active patient-year) by
candidate CPRA
0.8
Pre‐KAS
0.6
Post‐KAS
0.57
0.48
0.4
0.33
0.23
0.2
0.20 0.19
0.18 0.19 0.18 0.19 0.19 0.18
0.18 0.17 0.19 0.17
0.16 0.15 0.17 0.15
0.26 0.25
0.22
0.17
0.32
0.30
0.28
0.19 0.20 0.20
0.19
0.13
0.10
0.03
0
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
Candidate CPRA


Post-KAS, transplant rates decreased markedly for CPRA 80-94 candidates.
Sharp increases for CPRA 99-100 candidates.
Table II.12
Offer & accept. rates by candidate CPRA
Offers received
25
20
24.9
Pre‐KAS
22.3
Post‐KAS
23.0
15
10
8.8
5
7.0
0
Candidate CPRA


Acceptance rates
25
% of offers accepted
Offers received per year
30
1.7
0.2
Pre‐KAS
20
Post‐KAS
18.8
15
10
7.4
5
0.7
3.2
0
Candidate CPRA
Offer rate curve smoother post-KAS, and higher for CPRA>95% patients.
Offer acceptance rates increase as CPRA increases.
Table II.13
Table III.5
CPRA 99-100% recipient “bolus effect”
20%
15.8%
15.5%
14.5%
13.4%
KAS implementation
% of transplants to CPRA 99‐100%
recipients
17.7%
10%
3.2%
1.7%1.6%
2.3%2.0%
13.4%
12.6%
11.8% 12.2%11.8% 12.3%
11.2%
3.5%
2.9%
2.9%2.5% 2.8%
1.8%
2.4%
0%
Transplant date

Transplants to CPRA 99-100% patients rose sharply after KAS but have
tapered to around 11-12%.
Table A.1d
Transplants by HLA mismatch level
100%
Pre‐KAS
Post‐KAS
91.8%
95.3%
100%
Pre‐KAS
Post‐KAS
75%
75%
50%
50%
25%
25%
8.2%
19.8%
80.2%
83.2%
16.8%
4.7%
0%
0%
0 ABDR Mismatch

1+ ABDR Mismatch
0 DR Mismatch
1+ DR Mismatch
Fewer 0-ABDR and 0-DR mismatch transplants occurred in the
post-KAS period.
Table II.1b
Offer rates and acc. rates by HLA mismatch level
% of offers accepted Rates of receiving offers
10
5
0.1
0.047
0.043
8%↓
33.8
30
% offers accepted (0MM)
15
% offers accepted (non‐0MM)
18.2
40
35
0MM offers per active patient year
Non‐0MM offers per active patient year
20.3
12%↑
25
20
15
10
0
Pre‐KAS
Post‐KAS


30
36%↓
10
0.97
0
Pre‐KAS
Post‐KAS
21.4
20
5
1.00
0
0MM
40
0.2
25
20
Non‐0MM
0MM
Non‐0MM
0
Pre‐KAS
Post‐KAS
0MM offers decreased 8% post-KAS.
Acceptance rates for 0MM offers dropped by 36%.
Pre‐KAS
Post‐KAS
Table II.13
Table III.5
Who’s getting transplanted under KAS?
Percentage of Deceased Donor Kidney Transplants by Recipient Duration on Dialysis
75%
Waitlist (11/30/2014)
Pre‐KAS (1 year)
Post‐KAS (1 year)
49.5% 49.8%
50%
41.1%
34.9%
26.2%
21.3%
25%
14.9%
9.1%
8.7%
5.7%
11.0%
7.9%
10.2%
5.2% 4.3%
0%
Preemptive
0‐1
1‐5
5‐10
10+
Recipient duration on dialysis (years)

More transplants are going to long dialysis duration recipients.

Fewer preemptive (before dialysis) transplants.
Offer & accept. rates by candidate time on dialysis
Offers received
Pre‐KAS
30
15
Pre‐KAS
28.7
23.1
25
20
7
Post‐KAS
21.7
18.7
17.0
16.1
16.9
16.4
19.9
17.5
15.7
12.0
10
5
0
Candidate duration on dialysis (years)


% of offers accepted
Offers received per year
35
Acceptance rates
Post‐KAS
6.4
6
5
4
3
1.7
2
1
0.8
0
0.5
0.9
0.9
0.7
0.9
2.3
1.5
1.2
0.7
Candidate duration on dialysis (years)
Offer rates increased post-KAS for high dialysis time patients.
Offer acceptance rates rose sharply for candidates with 10+ years on
dialysis and dropped for preemptive patients.
Table II.13
Table III.5
High dialysis time recipient “bolus effect”
20%
18.6%
KAS implementation
% of transplants to recipients with 10+ years on dialysis
16.6%
10%
5.5%
4.0%
4.8%
3.8%
4.2%
5.0%
12.1%
12.7%
11.1%
8.7%
8.1%
8.6%
7.5% 7.1%
6.9%
7.2%
4.3%
3.4%
0%
Transplant date

Transplants to recipient with 10+ years of dialysis rose sharply after KAS
but have tapered substantially.
Table A.1d
Who’s getting transplanted under KAS?
Percentage of Deceased Donor Kidney Transplants by Recipient Race/ethnicity
50%
Waitlist (11/30/2014) 41.8%
36.8%
34.3%
36.5%
Pre‐KAS (1 year)
Post‐KAS (1 year)
35.4%
31.5%
25%
19.2% 18.6%
17.0%
7.9% 7.3%
6.8%
0.6%
0.7% 0.7%
1.1%
1.2%
1.3%
0.5% 0.5%
0.5%
0%

More African Americans are receiving kidney transplants, although
less so during the 2nd six months.
Transplant rates (per active patient-year) by
candidate race/ethnicity
0.4
Pre‐KAS
0.21
0.2
0.17
Post‐KAS
0.23
0.22
0.20
0.19
0.16
0.15
0.15
0.17
0
African American
Caucasian
Asian
Hispanic
Other
Candidate race/ethnicity


Statistically significant increase in transplant rates for African
American (AA) and Hispanic candidates.
Offer rates up 20% and acceptance rates up 4% for AA candidates.
Table II.12
Who’s getting transplanted under KAS?
Percentage of Deceased Donor Kidney Transplants by Recipient Primary Diagnosis
50%
Waitlist (11/30/2014)
Pre‐KAS (1 year)
Post‐KAS (1 year)
33.3%
25%
27.8%
24.1%
24.6%
22.4%
21.5%
22.0% 22.5%
20.9%
7.8%
6.1% 5.8%
9.1%
7.3%6.9%
4.3% 3.9%
3.1%
5.2%6.1% 6.6%
2.8%2.6%3.3%
0%
Recipient Primary Diagnosis


More transplants for hypertensive nephrosclerosis and retransplant
patients.
Fewer transplants for diabetics and polycystic kidney disease patients.
Table 1.2a
Table II.1b
Who’s getting transplanted under KAS?
Percentage of Deceased Donor Kidney Transplants by Recipient Gender
100%
Waitlist (11/30/2014)
Pre‐KAS
Post‐KAS
59.8%
61.0%
59.4%
50%
40.2%
39.0%
40.6%
0%
Male
Female
Recipient gender


Transplants to female recipients increased slightly under KAS.
Highly sensitized patients tend to more often be female.
Table 1.2a
Table II.1b
Who’s getting transplanted under KAS?
Percentage of Deceased Donor Kidney Transplants by Recipient Blood Type
75%
Waitlist (11/30/2014)
Pre‐KAS (1 year)
Post‐KAS (1 year)
52.3%
50%
45.6% 46.1%
36.9%
34.9%
28.4%
25%
16.5%
12.8%13.0%
2.8% 4.7% 6.0%
0%
A
B
AB
O
Recipient blood type

The distribution of transplants has changed little by recipient ABO.

Slight increases for blood type B and AB patients.
A2/A2B subtype to blood type B recipients
Pre vs post-KAS summary
Metric
A2/A2B transplants
% of transplants
PRE-KAS
POST-KAS
19
109
0.2%
1.0%
A2/A2BB transplants have increased 5-fold.
 Occurred at 34 different programs.

Table II.9
Pediatrics, Highly Sensitized, and Prior Living Donors
15%
13.0%
Waitlist (11/30/2014)
Pre‐KAS (1 year)
Post‐KAS (1 year)
8.3%
4.2%
3.9%
2.5%
0.03%
0%
CPRA 99‐100
(N=9,148) (N=268)

(N=1,526)
0.40%
0.33%
Prior living donors
(N=30)
(N=44)
(N=37)
0.9%
Pediatrics
(N=984)
(N=463) (N=443)
Proportion of transplants relative to WL prevalence under KAS:

CPRA 99-100: 13.0/8.3 = 1.6
PLDs: 0.30/0.028 = 11
Pediatrics: 3.6/0.9 = 4.3
Table 1.2a
Table II.1b
Prior living donors’ access to transplants
Deceased donor transplant rates per active patient-year on the WL
Deceased donor transplants per active year
All candidates
CPRA 100%
Pediatrics
2.5
Prior living donors
2.37
2.26
2
1.11
1.5
1.03
1
0.5
0.32
0.19
0.18
0.03
0
Pre‐KAS
Post‐KAS

Pre‐KAS
Post‐KAS
Pre‐KAS
Post‐KAS
Pre‐KAS
Post‐KAS
Transplant rates for prior living donors are similar pre vs. post KAS
and much greater than all other kidney candidate populations.
Table II.12
Single vs. Dual vs. En bloc kidney transplants
Pre vs post-KAS summary
Metric
Single
Dual
En-bloc

PRE-KAS
N
PRE-KAS
%
POST-KAS
N
POST-KAS
%
10614
97.4%
11109
97.5%
96
0.9%
63
0.6%
191
1.8%
225
2.0%
Fewer dual kidney transplants post-KAS.
Table II.10
Multi-organ kidney transplants
Pre vs post-KAS summary
Multi-organ kidney
transplant type
All
PRE-KAS
N
PRE-KAS
%
POST-KAS
N
POST-KAS
%
1,370
11.2%
1,471
11.4%
Heart-Kidney
112
0.9%
134
1.0%
Kidney-Pancreas
702
5.7%
705
5.5%
Liver-Kidney (SLK)
542
4.4%
625
4.9%
14
0.1%
7
0.1%
Other

The proportion of transplanted deceased donor kidneys used in
multi-organ transplants has changed little.
Table II.11
KDPI distribution among deceased donor kidney transplants in 2015
KDPI
100%
908
90%
1
91
21-34%
35-85%
>85%
1
29
42
80%
70%
0-20%
182
262
6291
60%
35
50%
117
40%
30%
1807
443
68
20%
10%
217
2475
0%
KI alone (N=11,481)

SKP (N=717)
SLK (N=625)
KI with other organ(s)
(N=146)
Multi-organ kidney tx tend to have low KDPI.
Slide courtesy of Wida Cherikh and Anna Kucheryavaya, UNOS
Longevity-matching under KAS
Percentage of Deceased Donor Kidney Transplants by KDPI and Recipient Age
Recip age
Pre-KAS
KDPI
0-20
21-34
35-85
0-17
13.4%
4.9%
18-34
12.5%
35-49
26.4%
50-64
65 Plus
All
ALL
86-100
1.1%
0.2%
11.5%
7.7%
1.3%
8.8%
27.8%
24.6%
8.3%
24.1%
33.0%
38.8%
42.2%
45.3%
39.9%
14.6%
17.0%
24.4%
44.9%
22.9%
100.0%
100.0%
100.0%
100.0%
100.0%
Recip age
Post-KAS
KDPI
0-20
11.7%
6.8%
18-34
30.4%
35-49
38.7%
50-64
All

21-34
0-17
65 Plus
4.2%
ALL
35-85
86-100
0.3%
0.0%
3.9%
12.8%
7.2%
1.2%
12.8%
28.2%
26.2%
8.6%
27.9%
14.3%
37.8%
45.1%
47.8%
37.3%
4.8%
14.5%
21.2%
42.4%
18.1%
100.0%
100.0%
100.0%
100.0%
100.0%
Of KDPI 0-20% transplants, far more going to age 18-49 recipients,
far fewer to age 50+.
Table II.3b
100%
% Waitlist
Post‐KAS % transplants
80%
75%
74.4%
50%
25.5%
25%
20%
0%
EPTS 0‐20%
EPTS 21‐100%
Recipient EPTS Score

Transplants per active patient‐year
Post-KAS access to transplants by EPTS score
0.3
Post‐KAS
0.21
0.2
0.17
0.1
0
<=20%
>20% (or missing)
Candidate EPTS score
EPTS 0-20% candidates have moderately higher access to
transplants than EPTS 21-100% candidates under KAS,
including 20% higher transplant rates.
Table 1.2a
Table II.1b
Table II.12
Post-KAS offer and accept. rates by EPTS score
Offers received
Post‐KAS
2
21.1
20
17.6
10
0
% of offers accepted
30
Offers received per active patient‐year
Acceptance rates
Post‐KAS
1.2
0.9
1
0
<=20%
Candidate EPTS score


>20% or missing
<=20%
>20% or missing
Candidate EPTS score
Perhaps counterintuitively, offer rates were lower for EPTS 0-20% patients.
However, organ quality was better (lower average KDPI) and acceptance rates
for EPTS 0-20% patients were 30% higher than for EPTS 21-100% patients.
Table II.13
Table III.5
Table III.5a
Geographic distribution of kidney transplants
Pre‐KAS (1 year)
Post‐KAS (1 year)
21.4%
31.5%
8.8%
12.6%
18.8%
12.7%
68.5%
78.6%
Local

Regional
National
Local
Regional
National
More kidneys are being distributed outside recovery OPO’s DSA.
Table II.1b
Cold ischemic times for transplanted kidneys
25%
Pre‐KAS (1 year)
Post‐KAS (1 year)
18.0%
19.5%
19.0%
17.7%
18.3%
18.2%
15.6%
15.5%
14.1%
12.9%
11.4%
9.3%
3.5% 4.0%
1.5% 1.7%
0%
0‐4
4‐8
8‐12
12‐16
16‐20
20‐24
24‐36
>=36
CIT (hours)


Average CIT increased 6% from 17.0 to 17.9 hours
CIT> 24 hours - Pre-KAS: 19.0%, Post-KAS: 22.3%
Table II.1d (known CIT only)
Geographic distribution of kidney transplants
25%
Pre‐KAS (1 year)
Post‐KAS (1 year)
17.2% 17.5%
14.2%
13.0% 13.3%
12.6%
11.3%
10.9%
9.4% 9.7%
7.0%
7.0%
6.4% 6.2% 6.7%
6.4%
7.6% 7.8%
4.5%
3.8%
3.9%
3.4%
0%
1
2
3
4
5
6
7
8
9
10
11
OPTN Region


No substantial changes in most Regions.
Largest % increase: Region 9; Largest % decrease: Region 6
Table II.6
Transplant volume by DSA, pre vs. post-KAS
700
Post‐KAS solitary DD kidney tx
600
510, 581
500
400
300
258, 209
200
100
0
0
100
200
300
400
500
600
Pre‐KAS solitary DD kidney tx


N=36 (62%) of 58 DSAs had an increase in volume post-KAS.
One large DSA saw a 14% increase, from 510 to 581.
Table II.6
Transplant volume by center, pre vs. post-KAS
300
250
Post‐KAS solitary DD kidney tx
164, 236
200
114, 170
150
31, 95
100
86, 56
50
42, 15
0
0
47, 18
50
109, 65
69, 23
100
150
200
250
300
Pre‐KAS solitary DD kidney tx



N=124 (54%) of 230 programs had an increase or no change in volume.
One large center performed 72 (44%) more transplants post-KAS.
Many possible reasons for changes: (a) KAS + patient mix, (b) acceptance practices,
(c) OPO performance, (d) random variation, etc.
Table II.6
Transplant volume by center, pre vs. post-KAS
Small-volume centers (<50 transplants per year)
50
48, 46
45
45, 44
Post‐KAS solitary DD kidney tx
40
39, 41
35
30
25
20
0, 20
15
10
5, 9
15, 7
5
7, 5
0
0
5
10
15
20
25
30
35
40
45
50
Pre‐KAS solitary DD kidney tx


Substantial pre vs. post-KAS variability among small programs
Small-N center volume more likely to be affected by random variation
Table II.6
Deceased donor kidney recovery
and utilization
47
Deceased kidney donors recovered under KAS
Pre vs. post-KAS trends
Over time (per 30 days)
On average
639.0
674.5
658.2
666.8
555.5
500
KAS implementation
Number of kidney donors recovered per 30‐day period
756.8
0
Nov‐13
Mar‐14
Jun‐14

Sep‐14
kidney donors recovered per 30 days
1000
1000
636.4
675.8
6.2%↑
500
0
Pre‐KAS
Jan‐15
Apr‐15
Jul‐15
Oct‐15
(Total N=7,743)
Post‐KAS
(Total N=8,222)
Recovered kidney donor volume increased 6% post-KAS.
Table II.1a
Kidney recovery & utilization under KAS
Percentage of Recovered Deceased Kidney Donors by KDPI
60%
Pre‐KAS
Post‐KAS
51.0% 50.3%
40%
20.1% 20.6%
20%
15.2% 15.0%
13.8% 14.1%
0%
0‐20
21‐34
35‐85
86‐100
KDPI

Total kidney donors recovered per month increased 6.2% (636.4 to 675.8).

However, the distribution by KDPI has remained very similar.
KDPI based on 2014 reference population
Table III.1b
Kidney recovery & utilization under KAS
Kidney Discard Rate by KDPI – first six months
75%
Pre‐KAS
Post‐KAS
61.9%
55.6%
50%
25%
18.5% 20.2%
17.4% 19.2%
6.2% 7.3%
2.3% 2.0%
0%
0‐20
21‐34
35‐85
86‐100
Overall
Discard rates

Kidney discard rates increased by 1.7% points (about 10%).

Increase largest for, but not limited to, KDPI>85% kidneys.
Table III.3
Kidney recovery & utilization under KAS
Kidney Discard Rate by KDPI -- including months 7-10 (Jun – Sep ‘15)
75%
Pre‐KAS
61.9%
Post‐KAS (mos. 1‐6)
55.6%
Post‐KAS (mos. 7‐10)
56.0%
50%
25%
19.2%
17.4%
2.3% 2.0% 2.7%
20.2%
18.4%
18.5%
18.4%
6.2% 7.3% 6.6%
0%
0‐20
21‐34
35‐85
86‐100
Overall
Discard rates

Discard rates have returned to pre-KAS levels in recent
months.
Kidney recovery & utilization under KAS
Kidney Discard Rate by KDPI – one year pre vs. one year post-KAS
75%
Pre‐KAS
Post‐KAS
58.5%
54.8%
50%
25%
18.5% 19.3%
17.1% 18.2%
6.4% 6.6%
2.5% 2.6%
0%
0‐20
21‐34
35‐85
86‐100
Overall
KDPI

For the full year, discard rates rose from 18.5% to 19.3%. The
increase was most evident for KDPI 86-100 kidneys.
Kidney recovery & utilization under KAS
Kidney Discard Rate by DCD vs. BD
Pre‐KAS
25%
Post‐KAS
20.8%
18.6%
19.1%
17.6%
18.5%
19.3%
0%
Brain dead
DCD
Overall
Discard rates

The discard rate increased more for DCD donor kidneys.
Table III.3
Kidney recovery & utilization under KAS
Kidney Discard Reasons
PRE‐KAS
50%
POST‐KAS
33.0% 33.5%
28.9% 28.9%
25%
15.6% 15.2%
0%
Discard reasons

Reasons for discard similar pre vs post-KAS.
Table III.4
Disposition of offers accepted non-locally*
% NOT going to acceptor
(size of bubbles reflects relative number of accepted offers)
Pre‐KAS

Fewer non-local acceptances are
for CPRA 0-98 patients under
KAS (size of bubble)

Of these acceptances, about 1/3
have not gone to acceptor, pre
and post-KAS

Dramatic increase in number of
non-local acceptances for CPRA
99-100% patients (size of bubble)

DECREASE in % of kidneys not
transplanted to these acceptors
Post‐KAS
% NOT going to acceptor
(size of bubbles reflects relative number of accepted offers)
Pre‐KAS
Post‐KAS
Table III.6
Disposition of offers accepted non-locally*
All non-local acceptances
% NOT going to acceptor
(size of bubbles reflects relative number of accepted offers)
Pre‐KAS

Increase in number of non-local
acceptances

Decrease in % of kidneys not
transplanted to these acceptors
Post‐KAS
Net effects:
Increase from 92 to 114 per month in # non‐local acceptances not going to acceptor
 Six programs accounted for over half of post‐KAS cases.
Table III.6
Non-Locally Accepted Offers Not Txed to the Acceptor
Percent Discarded
(28%)
% of kidneys not accepted by acceptor that were discarded
100%
40%)
75%
(72% of accepts)
(60% of accepts)
50%
35.5%
36.2%
Pre‐KAS
Post‐KAS
25%
0%

Just over a third of kidneys accepted but not transplanted to the accepting patient
were discarded, pre and post-KAS.

The remaining two-thirds were transplanted into another recipient.
Table III.6
Early recipient outcomes
58
Delayed graft function (DGF) rates
% delayed graft function
30
29.2
24.4
20
Pre‐KAS
Post‐KAS

The percentage of recipients requiring dialysis within the first week after
transplant increased from 24.4% pre-KAS to 29.2% after KAS.

Increase appears to be driven mostly by more high dialysis time recipients.
Table II.16
Six Month Graft Survival
100
95.8
95.4
100
(28%)
(Zoomed‐in axis)
40%)
Log‐rank p‐value=0.20
% graft survival at 6 mos.
% graft survival at 6 mos.
90
80
70
60
50
40
30
20
(72% of
accepts)
95.8
(60% of
accepts)
95.4
10
0
90
Pre‐KAS

Post‐KAS
Pre‐KAS
Post‐KAS
Six month graft survival rate slightly lower but statistically no
different from pre-KAS.
Table III.6
Other Early Outcomes

Six-month patient survival rates



Pre-KAS: 98.04%
Post-KAS: 97.68%
(28%)
(P‐value=0.14)
Six-month recipient serum creatinine


40%)
Pre-KAS: median=1.30, p75=1.60
Post-KAS: median=1.32, p75=1.70
(72% of accepts)
(60% of accepts)
Table III.6
Summary: First Year of KAS

Overall – KAS is meeting key goals

Decrease in longevity mismatches

Increase in the number of transplants among very highly sensitized patients

Increase in access to transplant for African Americans candidates

“Bolus effects”: the percent of transplants to CPRA 99-100% and
dialysis>10 years recipients are both tapering post-KAS

Increase in A2/A2BB transplants, but still room for growth

Transplant volume up 4.6%
Summary: First Year of KAS (cont’d)

No change in waiting list mortality rates

Six-month graft and patient survival rates similar to pre-KAS

Several trends deserve further attention:

Fewer 0MM transplants

Slight drop in pediatric transplants will continue to be tracked closely

Logistical challenges in allocation

Increased CIT and DGF

Increase in discard rates, particularly KDPI>85% kidneys.
UNOS Research Department
Data Quality Team
Catherine Monstello, RRT, CPHQ
John Beck, MSME
Sherri Williams
Brooke Chenault, CCRA
Jessie Maker, MS
Tammy Snead
Tenisha Atobrah
Penny Brock
Sharon Graves
Clay McDonald
Rashonda Ogletree, MS
Jo Smith
Health Informatics Team
Tim Powell, MPH, CPHI
Harris McGehee
Data Analytics Team
Sarah Taranto
Tim Baker
Jude Maghirang, MS
Yulin Cheng
Eric Beeson
Harpreet Singh, PhD
Alex Garza
Heather Neil
Denise Tripp
Ann Harper
Jaime Williamson
Wes Rosson
Scientists and Analysts
Leah Edwards, PhD
Erick Edwards, PhD
Wida Cherikh, PhD
Bob Carrico, PhD
John Rosendale, MS
Darren Stewart, MS
Jennifer Wainright, PhD
Marissa Clark‐Quimby, MS
Amber Wilk, PhD
Anna Kucheryavaya, MS
Mike Curry, MS
Read Urban, MPH
Victoria Garcia, MPH
Leadership
Ryan Ehrensberger, PhD, FACHE
David Klassen, MD
Cherri Taylor