Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards

NEW YORK, Oct. 22, 2018 /PRNewswire/ -- The organ supply shortage is a major challenge facing the field of whole organ transplantation and affects the nearly 100,000 Americans waiting on a kidney right now.  Today, a new report focused on decreasing the number of kidneys discarded aims to address some of the key factors and provides the first systematic nationwide approach to reducing kidney discards.  Approximately 12 people die each day waiting for a kidney transplant while about 10 kidneys are discarded daily. 

Published online today in the journal Clinical Transplantation, the Journal of Clinical and Translational Research, the "Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards" is the result of a year-long effort with leading transplantation experts in the United States devoted to solving the kidney utilization problem.

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. 

"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," said Matthew Cooper, MD, Co-Chair of the NKF Consensus Conference to Decrease Kidney Discards. Stakeholders include transplant centers, Organ Procurement Organizations (OPOs), the Centers for Medicare & Medicaid Services (CMS), The Health Resources and Services Administration (HRSA), United Network for Organ Sharing (UNOS), National Institutes of Health (NIH), transplant and donation societies, private payers and patients waiting for transplant. 

"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," said Joseph Vassalotti, MD, Chief Medical Officer, National Kidney Foundation and a board-certified nephrologist.  "Because there is no universally applied method to determine which kidneys are used for transplant and which are discarded, we need clear and definitive interventions, combined with collaboration with Organ Procurement Organizations and local transplant centers, to increase the use of these kidneys and the chances of patients to find their match." 

The recommendations chronicled in today's 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.   

"The Kidney Discard Conference provided me with details that I was unaware of and enabled me to ask thought provoking questions to kidney transplant centers when considering them for my next kidney," said Nichole Jefferson of West Des Moines, IA and a kidney transplant patient. "The first transplant I received was 10 years ago after being on dialysis for four and a half years. After the conference, I realized there were probably several kidneys that were offered; however, they were possibly passed up by my clinic.  I am now relisted for a kidney again due to the failure of my first transplant and this time, I hope to receive a transplant before having to start dialysis."

The 14 specific recommendations in today's online published report 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.

"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," said Stephen Pastan MD, Renal Division, Department of Medicine, Emory University School of Medicine. "I am grateful to the National Kidney Foundation for providing the leadership to convene this conference, and to work for the implementation of the conference recommendations."

Report authors include Matthew Cooper, MD, Medstar Georgetown Transplant Institute, Georgetown University, Washington, DC; Richard Formica, MD, Department of Medicine, Section of Nephrology, Yale School of Medicine, New Haven, CT; John Friedewald, MD, Northwestern Medicine Comprehensive Transplant Center, Chicago, IL; Ryutaro Hirose, MD, Department of Surgery, University of California San Francisco, San Francisco, CA; Kevin O'Connor, President and CEO, LifeCenter Northwest, Bellevue, WA; Sumit Mohan, MD, Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Jesse Schold, PhD, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; David Axelrod, Lahey Hospital and Medical Center, Burlington, VT; and Stephen Pastan, MD, Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, GA.   

The Conference leadership and all involved including NKF, patients, CMS, UNOS, OPOs, are continuing the dialogue and active participation toward the goal of increasing the utilization of procured kidneys to avoid discard and providing opportunities for transplantation that are currently falling short of the demand. These initiatives include ongoing advocacy efforts with federal agencies to ensure kidneys at high risk for discard are reaching patients; the development and distribution of patient education materials; and a collaborative partnership with all stakeholders to address the issues contributing to discarded kidneys. 

About Kidney Disease
In the United States, 30 million adults are estimated to have chronic kidney disease—and most aren't aware of it.  1 in 3 American adults are at risk for chronic kidney disease.  Risk factors for kidney disease include diabetes, high blood pressure, heart disease, obesity, and family history. People of African American, Hispanic, Native American, Asian, or Pacific Islander descent are at increased risk for developing the disease.  African Americans are 3 times more likely than Whites, and Hispanics are nearly 1.5 times more likely than non-Hispanics to develop end stage renal disease (kidney failure).

The National Kidney Foundation (NKF) is the largest, most comprehensive and longstanding organization dedicated to the awareness, prevention and treatment of kidney disease. For more information about NKF, visit www.kidney.org

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