Reducing discards of deceased donor kidneys

Some changes that could lead to transplantation of more deceased donor kidneys:

KAPP Implements Recommendations from NKF Kidney Discards Conference

"New York, NY—July 17, 2019—Today the Organ Procurement and Transplantation Network (OPTN) announced the launch of the Kidney Accelerated Placement Project (KAPP) to assess whether accelerating the placement of extremely hard-to-place kidneys via the Organ Center can increase their utilization. This significant step is derived from recommendations outlined in a report by the National Kidney Foundation and published in the journal Clinical Transplantation, the Journal of Clinical and Translational Research, the “Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards” in October, 2018. The report focused on decreasing the number of kidneys discarded and provided the first systematic nationwide approach to reducing kidney discards.
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"The 14 specific recommendations in the published in the Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards are:

• Strengthen local Organ Procurement Organization (OPO) and transplant center cooperative Quality Assurance and Performance Improvement (QAPI) efforts to reduce discard to identify the root causes of failure to place kidneys locally and implement solutions to increase allocation.
• Improve communication between OPO and Accepting Transplant Surgeon at time of organ placement to improve information used to make acceptance decisions.
• Routinely send prospective crossmatch 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 DSA for shared allocation of high Calculated Panel Reactive Antibodies (CPRA) or high KDPI 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 that consider downstream risks of acceptance versus refusal of a given kidney for each specific patient.
• 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.  Center must sustain high rates of acceptance to receive offers.
• Identify organs that become a risk for discard during standard allocation and allocate them 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.
• Standardize technical aspects of obtaining and interpreting renal (deceased donor) biopsies to utilize renal pathologists to improve decision making based on biopsy.
• Standardize provision of gross photos of procured kidneys and post on DonorNet to better inform the surgeon on condition of procured organ.
• Develop 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.

About Kidney Discards

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 (KDPI) grafts, the report points out, yet experts believe and data supports that many of these kidneys can be used for transplant. Kidney discard rates also vary upon geography leading experts to believe that the variation may be based on a subjective view of organ viability by an individual transplant team.  Every year kidneys that could be used for transplant are discarded.  In 2016, more than 3,600 were deemed unfit for transplant and thrown away.  But a panel of transplant experts convened by NKF agree that as many as 50% of those kidneys could be transplanted to prolong the lives of Americans otherwise treated with dialysis. The recommendations chronicled in the published report emerged from NKF’s Consensus Conference to Reduce Kidney Discards, held in May 2017 with 75 multidisciplinary experts in the transplant field including kidney patients and families."

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From the 2018 "Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards," by Matthew Cooper  Richard Formica  John Friedewald  Ryutaro Hirose  Kevin O’Connor  Sumit Mohan Jesse Schold  David Axelrod  Stephen Pastan

"4 EFFECT OF THE REGULATORY ENVIRONMENT ON KIDNEY DISCARD

The current regulatory environment may impact the kidney discard rate by increasing risk aversion on the part of transplant centers.26, 27 Transplant centers are held accountable for one‐year graft and patient survivals, and there are concerns regarding how the use of high KDPI kidneys, or those with long cold ischemic times, will impact center ratings. Empirical evidence indicates that poor center performance ratings are associated with a decline in transplant volume.28, 29 This effect persists despite analyses demonstrating that donor factors are adequately captured in the risk adjustment models.30 Overcoming the concern of the influence of donor risk on center outcomes will require both continued education and research. Additionally, because there are perceptions of the limitations of risk adjustment for recipient factors, testing the effect of exempting certain organs from inclusion in center outcomes may reduce risk aversion. In fact, in 2017, the Membership and Professional Standards Committee of the OPTN instituted a new operational rule to exempt transplants from a donor with a KDPI of 85 or higher transplanted into a recipient with an EPTS greater than the 80th percentile, that is,a high‐risk donor into a high‐risk recipient. Although CMS has not endorsed a similar policy, this “natural experiment” may help to inform the transplant community regarding the effect of the regulatory environment on decision making, and inform other prospective policies that impact organ utilization.

New criteria for rating transplant centers should incorporate the potentially reduced graft survival of higher risk donor kidneys; this would remove the current disincentives that exist to use these kidneys.31 The development of more comprehensive metrics may improve alignment of transplant center and patient incentives and increase organ utilization. This approach would benefit older patients who through accepting higher risk kidneys could experience shorter waiting times, or avoid dialysis through preemptive transplantation. Additionally, society would benefit through an overall reduction in health care costs."