Reasons for Match Offer Refusals and Efforts to Reduce them ...

Reasons for Match Offer Refusals and Efforts to Reduce them ...

Effects of New KPD Histocompatibility Policy on Refusal Rate and Transplants R Leishman1, M Aeder2, M S Leffell3, C Murphey4, N Reinsmoen5, S Saidman6, T Sandholm7, A Toll1, A Harper1 and NTurgeon8 UNOS, Richmond, VA 2Univ Hosp Med Ctr, Cleveland, OH 3Johns Hopkins Univ, Baltimore, MD 4SW Immunodiagnostics, San Antonio, TX 5CedarsSinai Health, Los Angeles, CA 6Mass Gen Hosp, Boston, MA 7Carnegie Mellon Univ, Pittsburgh, PA; and 8Emory Univ, Atlanta, GA. 1 ATC 2017 Chicago, IL [email protected] 1 The Joint Annual Congress of the American Society of Transplant Surgeons and The American Society of Transplantation Ruthanne Leishman RN, MPH OPTN KPDPP Program Manager UNOS, Richmond, VA, USA

I have no financial relationships with commercial interests to disclose AND My presentation does not include discussion of off-label or investigational use. Acknowledgments This analysis reflects work performed on behalf of and in conjunction with the OPTN Kidney Transplantation Committee and the Kidney Paired Donation Work Group. This work was supported wholly or in part by Health Resources and Services Administration contract 234-2005370011C. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. Remaining 48% (n=160) Actual Match Offer Refusals 34.4% Donor-related

32.6% Crossmatch-related 21.9% Candidate-related Other 13.8% Match Runs: Jan-Sep 2014 4 Background: Crossmatch-related refusal reasons Match Runs: Jan-Sep 2014 (n=52) 34.62% 65.38%

Positive Virtual Crossmatch Virtual +crossmatch can be due to: Non-required donor antigens not entered (HLA-DQA1, HLA-DQB1, and HLA-DPB1) Non-required donor antigens not screened Candidate unacceptable antigens not entered or updated Positive Physical Crossmatch 5 Solution Implement KPD histocompatibility requirements

Goals Reduce the number of match offer refusals related to positive crossmatch Increase match offer success rate (define as # of offers that results in transplantation) 6 KPD Histocompatibility requirements policy Implemented January 21, 2016 Donor All HLA-DQA1, HLA-DQB1, and HLA-DPB1 required donor HLA screened against candidate unacceptable antigens Specific

candidate screening requirements Serological split level molecular typing Solid-phase single phenotype or solid-phase single-antigen test to identify unacceptables antigens Candidate unacceptables reviewed by 2 individuals, prior to first match run Retesting candidate: Every 110 days When any potentially sensitizing event occurs When reactivating a candidate, if inactive more than 90 days When a match is refused due to unacceptable physical crossmatch 7 Methods XM refusal rates were compared for pre (6/2/141/21/16) vs post (1/22/162/2/2017) policy periods. A logistic

regression model analyzed match outcomes of transplanted or not transplanted, controlled for the time periods, candidate CPRA, candidate age, donor age, donor BMI, and donor ABO. 8 Results Decrease in XM related refusals Percentage of refusal reasons by category: pre vs post policy implementation 50% 44% 45% 40% 35% 30% 32%

29% 33% 27% 25% 20% 15% 14% 13% 12% 10% 5% 0% Crossmatch Candidate

Pre-policy Donor Other Post-policy 9 Results Match Success Rate Univariate Analysis Pre-Policy: 5% Post-Policy: 10% p < 0.001

Logistic Model 118% increase in odds p < 0.001 Only significant factor after adjusting for other covariates 10 Discussion Decrease in refusal rate related to unacceptable crossmatches

Increase in match success rate Many highly sensitized candidates became ineligible after implementation, decreasing the mean CPRA of matched candidates decreased The mean CPRA of eligible candidates is now increasing as unacceptables are updated. Longer term analysis will determine whether the increased probability of transplant resulted from the policy's intention vs ineligibility of some sensitized candidates.

Further improvements to the program will be based on longer term findings. Now looking at donor-related refusal reasons 11 Thank you! 12

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