The New Kidney Allocation in Ontario,
First Year Look Back
Jeff Zaltzman
Director Transplant St. Mikes
CMO Transplant TGLN
Co- Chair Kidney-Pancreas working group
Objectives
① Discuss rational and principles for new Kidney
allocation in Ontario
② Review outcomes after the first year of
implementation
My conflicts
I am the director of a transplant program in
Toronto
I work at Trillium Gift of Life Network
Why change ?
• Expert Panel Report-access issues
• Auditor General report-access issues
• Ontario was only OPO region in: Canada, USA,
Euro-txp, UK, with multiple kidney and pancreas lists
• In Ontario all other organs: lungs, heart, livers were
on a single list
• The previous system was out-dated, and difficult to
manage
…….and for over 40% of the cases we reviewed, the
highest-priority patient did not receive the organ and
no reason was documented.
….. 90% of kidney recipients received a kidney within
four years in one Ontario region, compared to about
nine years in two other Ontario regions.
Average wait-time for kidney by region and
age (includes on Hold) 2010-11
2500
2000
1500
1000
500
0
19-55
>55
Average Waiting Time (days)
Ottawa
1636
1526
Hamilton
1522
1557
Kingston
1499
1073
London
910
805
Toronto
2179
1948
Regional Average
1781
1626
Why change?:Better outcomes
• New technology with regard to matching. Can
allocate based on acceptable mismatch, known
DSAs
o Better short and long-term outcomes
o Obviate need to cross DSA barriers
• Be consistent with what we were doing with
National Kidney Paired Donation and with Highly
Sensitized Program
• Some improvement in access to kidneys
•
•
Waiting times
sensitized
Why was this the right
time?
• HLA technology
• Ontario’s organ donor #s are now best in the
country
• The growth in organ donation has occurred in the
regions where it had to grow! : GTA and HAMILTON
• Easy to accommodate CBS National Highly
Sensitized Registry for recipients with cPRA >95%
Ontario 2014. 265 Deceased donors, including 76
300
(28%) DCD. A record for both!
250
200
DCD
150
NDD
100
50
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Pop: 13,500,000
RPM=19.6
Deceased Organ Donor Trends Canada 2001-2014
600
500
400
BC
Praries
300
Ontario Total
Ont NDD
Quebec
200
ATL
CANADA
100
0
Trends in deceased donor rate per million by province
30
25
Canada
BC
AB
SK
MB
ON
QU
NS
NB
NL
20
15
10
5
0
2010
2011
2012
2013
2014
TGLN 2001-2014: Which donor regions
saw the most growth ?
• TGLN 2001-2005- 141 donors per year
• TGLN 2006-2008- 182 donors per year
• TGLN 2009-2012- 223 donors per year
• TGLN 2013-2014- 245 donors per year
TGLN 2001-2014: Which donor regions
saw the most growth (last 12 years) ?
London, Hamilton, GTA, Kingston, Ottawa ?
•
•
•
•
•
London-5%
Hamilton-120%
GTA -65%
Kingston- 15%
Ottawa-10%
Problems with old allocation system
Based on priorities, but no weighting applied
Multiple lists, difficult to administer and allocate
Required negative cross-match for allocation
HLA labs for each of the 5 regions, but no access
between regions. Thus kidneys moved between
regions to recipients without knowing “matching”
⑤ Transplanted across DSA barriers
⑥ Belief that donors belonged to the transplant
program
⑦ Unequal access in terms of wait-times and
sensitized recipients
①
②
③
④
Old Allocation vs New allocation
Old
February 12, 2014
Don’t Share Kidneys
 share 1 kidney Nationally
and/or provincially
 Sensitized patients in Ottawa
have access to ~13 million
(highly sensitized~34 million)
Sensitized patients in Ottawa
have access to 1 million
potential donors
Allocation based on crossmatch
Allocation based on
dichotomous variables
(PRA>80% or 20-79%)
Transplant with donor
antibody present (DSA)
 Allocation done virtually
 Allocation will be
continuous(point system based
on cPRA and wait-time)
 Eliminate transplant against
DSA
What is virtual cross match?
• 1) Know all HLA antibodies of recipients on wait-list
at the molecular level
• 2) Donor antigens known at time
Potential donor, if the recipient does not have any
Donor Specific Antibodies (DSA)
ie : if recipient has antibodies against HLA : Dr11*0401,
then donor who expresses this antigen will not be a
match.
Sensitized patients: Ontario and Canada
• All recipients have a cPRA (0-100%)
• Patients across Ontario will have access to donors
throughout the province.
• A recipient receives points based on the following:
POINTS = 0.1 every 30 days wait from start of RRT + 4 x (%cPRA)/100
-Example patient has been on on dialysis 600 days and cPRA 0f 50%
0.1x 600/30 + 4 (50/100) = 4 points
 All patients with cPRA of 95% or greater now
registered on CBS National HSP. Eligible for kidneys
from anywhere in Canada ( based on virtual xmatch)
 Donor region will have maximum export #, and will
not export any more kidneys until below export
threshold
New kidney allocation for Ontario
• Use same priorities as in past , but assign weighting
• All recipients have know DSAs in system
• Allocate based on acceptable mismatching
• Goal : improve access to sensitized patients and
improve transplant outcomes, improve, but not
eradicate wait-time discrepancies between
programs
• Also able to apply changes to deal with blood
group wait-time discrepancies ie: A2 to B recip.
Principles of kidney Allocation
Keep 1, Share 1
• 1) “Old” donor regions remain
• 2) First kidney stays in local donor region
• 3) Second kidney offered first to National HSP, then
to next highest priority patient in Ontario
KIDNEY ALLOCATION IN ONATRIO
Principles:
All Ontario recipients whave high quality cPRA, HLA and acceptable
antigen mm entered into TGLN data base
Organ offers will made after negative virtual cross match with donor
2 separate allocations SCD and ECD (regardless of NDD or DCD)
First kidney stays in traditional transplant region, and second allocated
to provincial or National HSP wait-list. However allocation rules
remain the same for both. If only one kidney, than its allocated to
transplant/donor region.
All SCDs (<35) will be considered for pediatric recipients, for adults will
use age matching criteria as currently applied.
ALL ECD allocated to ECD recips (criteria set)
PRIORTIES of ALLOCATION (SCD, both NDD,DCD)
Starting point is virtual negative cross-match with donor:
1) OVERRIDING PRIORITY=Medical high priority
2) HIGH PRIORITY:
-Pediatric
-Multiorgan
-KP
3) MEDIUM PRIORITY: Age matching ;<35 year old donor to <55
year old recipient
Once donor recipients are allocated into the 1 of the 3 categories,
use total points to determine further allocation using the following:
Total Points= 0.1 point/month waiting + (0-4 points) for
sensitization- 4x cPRA/100
SAME PRIORITIES FOR ECD, but no pediatric consideration,
(Would still allocate ECD to overriding priority recipients)
3 goals
1) Improve access for Ontario
kidney wait-list patients
-organ redistribution
- referral redistribution
2)Improve outcomes
-avoid transplanting against donor
specific antibodies
3) Minimal
effect on transplant
Program activity
Try to balance these, but be aware of
impact to program activity
High priorities
sensitization
Waiting time
-Depending on weighting of these, the flow of kidneys could increase or decrease
-If we tried to equalize wait-time, then could compromise program activity!!!-
Improve access, and mitigate transplant
program volume effects
Reallocation of patient referrals
GTA has~50% of dialysis population but 63% of kidney wait-list
(675/1075)
o This will help to mitigate some access re wait-times, but
not completely
o Will offset concern re program transplant #s
o Remains patient focused, as can be done without causing
patients to travel further, and in most cases less travel than
current system.
Transplant referral by LIHN.
Goal: Shift referrals from GTA to London by way of Hamilton
Transplant OLD
center
LIHN
referral
Dialysis
New
Population LIHN
(%)
referral
Dialysis
Populatio
n
(%)
change 13% of
dialysis
on list
London
1,2, (14)
1017 (11)
1,2,3, 14
1530 (16.6)
+513
(+45%)
+67
Hamilton
3,4,
1407 (15)
4, 6
1806(19.6)
+399
(+22%)
+52
Toronto
5,6,7,8,9, 5459 (60)
12, 13,
14
5,7,8,9,12, 4547 (49)
13,14
-912
(-17%)
-119
Kingston
10
374 (4)
10
374 (4)
0
0
Ottawa
11
934 (10)
11
934(10)
0
0
Ontario
ALL
LIHNs
9191
9191
0
0
Dialysis #s by LIHN from 2007
OLD REFERRAL
London
Hamilton
Toronto
Kingston
Ottawa
NEW REFERRAL
-Referral base
-Population
-historical barriers
-Program viability
-Access (referrals, listing,
transplant)
-Blood group equity
-wait-time equity
-PRA equity
-Donor rates
-Trust
-National HSR
-Outcomes (measuring)
-Financial
.
FIRST YEAR RESULTS
Feb 12, 2014 -Feb 11,2015
ONTARIO: FIRST YEAR RESULTS
Reasons for Decline of Local Kidney
Region
London
Toronto
Kidneys
Number (%) of available local kidneys
available for February
that local program
chose
to use but
12th, 2014
– not
February
12th, 2015 Reason for Decline
local allocation
were transplanted elsewhere
No Suitable Recipient (N=7)
VXM and DCD (N=1)
40
10 (25%)
Medically Unsuitable (N=2)
No Suitable Recipient (N=2)
Medically Unsuitable (N=2)
112
7 (6%)
Not suitable in recipient OR (N=3)
Ottawa
15
0 (0%)
Kingston
11
5 (46%)
Hamilton
51
9 (18%)
\
-No Suitable Recipient (N=4)
Size (N=1)
No Suitable Recipient (N=4)
Medically Unsuitable (N=4)
Resources (N=1)
4 year mean #
60.7
86.8
76.8
60.5
39.0
9.8
7.2
cPRA and Virtual Cross Match
35
Trillium Gift of Life Network
cPRA of Kidney and Kidney/Pancreas Patients on the Wait List and Txped
100%
90%
22%
255
8%
25
6% 20
7%
80%
% of Patients
70%
60%
6%
68
12%
134
50%
13%
146
40%
8%
96
30%
15%
176
0%
7%
24
8%
26
7%
24
23%
268
8%
91
13%
148
13%
148
13%
53
58%
16%
179
14%
154
9%
29
30%
324
12%
10%
34
17%
59
21%
84
14%
57
26%
107
13%
51
12%
131
18%
196
5%
59
50
11%
44
≥95
18%
81-94
51-80
74
21-50
12%
22%
145
74
12%
136
29%
341
7%
87
9%
97
14%
152
9%
104
191
20%
10%
22
26%
293
8%
32
5% 21
15%
50
1-20
0
19%
13%
154
79
11%
133
15%
Unknown
63
26%
87
2%
25%
298
7
2% 24
24%
98
1%
6
2012 Wait List 2011/12 Tx 2013 Wait List 2012/13 Tx 2014 Wait List 2013/14 Tx 2015 Wait List 2014/15 Tx
Pre-Transplant Crossmatch Results for Kidney Only Patients
February 12th to February 11th, 2015
Pre-Transplant Crossmatches for Kidney Recipients
Total Number of donors that pre-transplant crossmatches were performed
Number of unique donor-recipient crossmatches performed
Negative (T-Cell)
Negative (B-Cell)
Positive T-Cell
HLA-Ab
Non-HLA Ab (includes 1 unknown with no clinical significance)
Auto
Unknown
Positive B-Cell
HLA-Ab
Non-HLA Ab (includes 2 unknown with no clinical significance)
Auto
3
37
7
n (%)
267
656
638 (97%)
642 (98%)
18
0
10
6
2
14
0
14
0
Allocation Points for Kidney Only Transplant Patients by ABO, Site
ABO
A
AB
B
O
3
38
8
N
Mean
SD
Median
Min-Max
N
Mean
SD
Median
Min-Max
N
Mean
SD
Median
Min-Max
N
Mean
SD
Median
Min-Max
HSC
KGH
7
4
3.1
8.8
2.8
4.4
3.3
7.2
0 - 8.1 4.8 - 15.1
1
2
2.3
9.6
0
4.9
2.3
6.2
2.3 - 2.3 6.2 - 13.1
3
0
2.4
0
1.9
0
1.7
0
1.1 - 4.6
0-0
6
5
3.9
7.1
1.9
5.1
3.9
6.7
0.3 - 5.9 2.5 - 15.7
LHSC
31
5.5
4.1
5.4
0 - 20.1
2
14.7
20.8
0
0 - 29.4
8
4.8
3.2
3.6
2 - 11.5
17
7
4.1
5.6
2.5 - 16.9
SJHH
39
6.9
3.7
6.2
1.2 - 16.1
6
3.7
1.4
3.4
2.3 - 6.2
6
11.4
8.3
10.3
2.7 - 25.2
21
7.3
3.8
6.9
0 - 18.6
SMH
31
7.1
5.6
4.6
0.3 - 26.8
5
7.5
1.7
7.1
5.8 - 10.4
20
11.3
3.4
11.4
4.3 - 16.1
24
11.1
2.1
10.6
7.7 - 15.2
TGH
45
5.9
3.4
5.3
0 - 17.8
9
4.7
2.5
5.2
1.6 - 9.9
15
10.5
4.7
10.2
4.9 - 19.2
20
10.5
2.6
10.9
6.2 - 14.6
TOH
24
8
7.4
4.1
0 - 30.3
5
6.9
4.6
4.6
3.5 - 14.5
4
9.9
8.3
6.5
2.8 - 21.9
19
8.9
4.1
8.2
0 - 16.7
ALL
181
6.5
4.7
5.3
0 - 30.3
30
6.3
5.5
5.2
0 - 29.4
56
9.6
5.4
9.8
1.1 - 25.2
112
8.7
3.9
8.6
0 - 18.6
Kidney Only Transplant Wait Times by ABO
Median
8000
Mean
7000
Number of Days
6000
5000
4000
3000
2000
1000
0
A
AB
B
O
Total
Count
Mean
181
30
56
112
379
1557.8
1377.6
2387.3
1999.6
1796.7
SD
1256.8
1379.8
1494.3
1031.3
1286.1
Median
1247.0
1028.0
2295.0
1949.0
1467.0
Min-Max
3 - 9093
177 - 7631
58 - 6372
1 - 4409
1 - 9093
Ontario Blood group donors/Recipients
50
45
40
35
%
30
DONORS
25
RECIPIENTS
20
SMH RECIPIENTS
15
10
5
0
A
B
AB
O
Some help for blood group B recipients
• 10% of blood group A donors are A2 (lower antigen
expression)
• Can Use A2 donors safely for B recipients when antiA titres are1:8 or less
• Programs will identify B recipients with Anti-A Ab of
1:8 or less
• These B recipients now prioritized to receive A2
donor kidneys
Summary
1)
2)
3)
4)
5)
Virtual Cross match system is working well
More sensitized recipients getting transplanted
Previous models predicted flow of kidneys
No “Risk’ to transplant program activity
Equal access across regions may take 5 years to
achieve
6) Access based on blood type is still an issue
Acknowledgements
THANKS TO:
• Members of Kidney Pancreas working group of
TGLN
• Transplant hospitals and all supporting staff
• Referral centers
• ORN
• MOHLTC
Discussion