Liver and Intestinal Organ
Transplantation Committee
Spring 2014 Update
Policy Implementation

Share 15/share 35/national share for
combined liver-intestine candidates –
implemented June 17, 2013


Committee monitor impact of these changes
HCC imaging criteria: October 31, 2013
Recent Public Comment Proposals
Adding serum sodium to the MELD score

Public comments: 78.6% supported

Regional votes/comments: 8 in favor, 2
opposed, 1 approved with amendment

ASTS supported, AST opposed

Board did not approve; Committee will
resubmit proposal in June 2014
Ongoing Committee
Initiatives
Designing Liver
Distribution for Geographic
Equity
Motivation: Transplant Rates, by OPO
MELD 38-39: 18% to 86%
Massie/Segev, AJT 2011
Motivation: Death Rates, by OPO
MELD 38-39: 14% to 82%
Massie/Segev, AJT 2011
Final rule: “Neither place of
residence nor place of listing shall
be a major determinant of access
to a transplant.”
Nov 2012 OPTN board resolution
** RESOLVED, that the Board of Directors approve the following
position regarding geography in organ allocation:

The existing geographic disparity in allocation of organs for
transplant is unacceptably high.

The Board directs the organ-specific committees to define the
measurement of fairness and any constraints for each organ system
by June 30, 2013. The measurement of fairness may vary by organ
type but must consider fairness based upon criteria that best
represent patient outcome.

The Board requests that optimized systems utilizing overlapping
versus non-overlapping geographic boundaries be compared,
including using or disregarding current DSA boundaries in allocation.
Designing Liver Distribution for Geographic
Equity - Recent Activity

2011: SRTR asked to further explore optimization
algorithms

2012 OPTN Strategic Plan, Objective A: Reduce
geographic disparities in access to transplantation
 Strategy:
Promote broader distribution of organs
 Key initiatives:

Examine SRTR study of regional boundary effects
on liver distribution

Examine the effectiveness of the current DSA and
regional boundaries and consider developing a new
method for distribution of organs to replace the use
of DSAs and regions
Designing Liver Distribution for Geographic
Equity - Recent Activity (Cont’d)

November 2012: Board tasks Committees w/
Disparity Metrics


Liver Committee Metric: Variance of median
MELD at transplant across DSAs
March 2013: Liver Committee Key Decisions
 Number of districts between 4 and 8
 Minimum number of transplant centers per
district: 6
 Waitlist deaths must not be statistically
significantly higher
Designing Liver Distribution for Geographic
Equity – Committee Progress Report

September 2013: Reviewed drafts of maps

Next steps:
 Continued evaluation of impact of redistricting and
comparison between 4 and 8 districts
 Impact on pediatric patients
 Impact on minorities
 Waiting list deaths by DSA/District
 Shift in livers by DSA/District
Will report out as more decisions are made
Gentry, et al, AJT, August 2013


Designing Liver Distribution for Geographic Equity
Broader Issues for Discussion

Impacts of OPO performance

Committee and POC discussing overarching issues
 Administrative Regions/RRBs
 Contiguous/ non-contiguous
 Multiorgan issues
 Role of DSA?
 Organs other than livers – metrics?
Update

The Committee will meet on April 1, 2014

Review latest maps

Cost data to be available

Stay tuned
Ongoing Committee Initiatives

Review of MELD/PELD exceptions and
RRB practices

Working on guidelines for new standardized
exceptions

Training materials for RRBs

National Review Board
Questions?

David Mulligan, MD, Committee Chair
David.Mulligan@yale.edu

James Pomposelli, MD, PhD
Region 1 Representative
James.J.Pomposelli@lahey.org

Ann Harper, Committee Liaison
Ann.Harper@unos.org