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Study identifies ways to reduce kidney discards
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A set of recommendations developed by a National Kidney Foundation-led consensus conference on reducing the discard rate for kidneys includes developing a risk-adjusted payment system for transplanting high-risk kidneys, improving communication between a nephrologist and surgeon regarding the risks of using the organ and developing a better alert system so more than one hospital can have access to the kidney.
The 14 recommendations are published as the “Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards.” The work and consensus conference involved 75 multidisciplinary experts in the transplant profession and included kidney patients and families.
Some recommendations in the online published report include the following:
Strengthen local organ procurement organization (OPO) and transplant center cooperative quality assurance and performance improvement (QAPI) efforts to reduce the discard rate. This may help identify the root causes of failure to place kidneys locally and implement solutions to increase allocation.
Improve communication between the OPO and the accepting transplant surgeon at the time of organ placement to improve information used to make acceptance decisions.
Routinely send prospective crossmatches to at least three transplant centers to speed up time to acceptance in case initial centers do not accept the kidney.
Grant “local backup” to centers receiving exported kidneys to ensure shipped organs can be used at first destination.
Identify “local backup” in local donation service area for shared allocation of high calculated panel reactive antibodies (CPRA) or high kidney donor profile index kidneys to decrease the need for organ export.
Expand use of virtual crossmatching to decrease the time to decision on acceptance by avoiding the need for testing of shipped specimen prior to transplant.
Involve the nephrologist working cooperatively with the surgeon in decisions regarding organ acceptance to share responsibility and utilize the medical knowledge of the nephrologist in acceptance decisions.
Improve practitioner and patient education on acceptance of higher risk for discard kidneys to prevent delays in acceptance and speed up decisions regarding kidney acceptance.
Disseminate best practices from OPOs and transplant centers that routinely accept high-risk organs to increase the number of centers which utilize high-risk organs.
Create expedited placement pathways to directly offer organs at risk of discard to small subset of centers that opt-in to accepting these organs.
Identify organs that become a risk for discard during standard allocation and allocate these to patients in rescue centers that utilized high-risk organs when standard placement has been unsuccessful to place limit on time that the kidney is in standard allocation pathway to ensure it is transplanted.
Develop a risk-adjusted payment system to cover increased costs of high-risk kidneys to remove disincentive to accept the organ which may result in an increased risk of post-transplant morbidity with associated cost.
“This conference demonstrates what can be done when the renal community works together to solve the problem of kidney discards, which is preventing many on the waiting list from receiving a kidney transplant,” Stephen Pastan, MD, of the renal division in department of medicine at Emory University School of Medicine, said in the NKF press release. “I am grateful to the NKF for providing the leadership to convene this conference, and to work for the implementation of the conference recommendations.”
There are many reasons why kidneys are discarded, including poor organ quality, abnormal biopsy findings, prolonged cold ischemic time, anatomy, punitive regulatory and payer sanctions due to poor clinical outcomes and the increased costs associated with the use of higher kidney donor profile index grafts, the report points out. Yet, experts believe and data support that many of these kidneys can be used for transplant. Kidney discard rates also vary upon geography, leading experts to believe the variation may be based on a subjective view of organ viability by an individual transplant team.
“This kidney discard conference report championed by the National Kidney Foundation represents the first undertaking of all stakeholders in the field of kidney transplantation to further an exhaustive effort to work collaboratively and cohesively toward removing barriers to increase the number of kidneys available for transplantation from deceased donors, and providing support and incentives to ensure no organ is wasted for those most in need,” Matthew Cooper, MD, co-chair of the NKF Consensus Conference, said in the release.
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