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Addressing Medically Urgent Candidates in New Kidney Allocation Policy

Proposal Overview

Status: Public Comment

Sponsoring Committee: Kidney Transplantation

Strategic Goal: Provide equity in access to transplants

Read the proposal (PDF; 01/2020)

Contact: Tina Rhoades

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eye iconAt a glance

What is current policy and why change it?

Currently, if a physician determines that a kidney candidate’s condition is serious enough that they need a transplant immediately, they have the option to request approval from all other transplant hospitals in the same Donation Service Area (DSA) to give the candidate priority over others when a kidney is available. In December 2019, the OPTN Board of Directors approved a new kidney allocation policy that will replace DSAs with a 250 nautical mile circle around each donor hospital. This means that there will no longer be a standing set of transplant hospitals to approve requests for priority due to medical urgency. To make sure that this priority is used consistently, a defined practice to award this priority is necessary.

What’s the proposal?

  • Defines a medically urgent candidate.
    • Unable to receive dialysis or at high risk for not being able to receive dialysis.
  • The candidate receives priority when a kidney is available within a 250 nautical mile circle.

What’s the anticipated impact of this change?

  • What it’s expected to do
    • Replace the existing medical urgency exception policy to align with the recently approved changes to kidney allocation policy.
    • Help medically urgent kidney candidates get transplanted quickly.
    • Ensure candidates receiving this priority meet a consistent definition of what is considered medically urgent.
  • What it won’t do
    • Apply to every kidney candidate on the wait list.

Themes to consider

  • Qualifying medical urgency criteria
  • Supporting evidence of criteria
  • Appropriate priority over other candidates

Terms you need to know

  • Donation Service Area: The geographic area designated by the Centers for Medicare and Medicaid Services (CMS) that is served by one organ procurement organization (OPO), one or more transplant hospitals, and one or more donor hospitals.
  • Donor hospital: The hospital where the deceased or living donor is admitted.
  • Nautical mile: Equal to 1.15 miles and is directly related to latitude and longitude; used in aviation.
  • Click here to search the OPTN glossary.

Comments

Michael Moritz | 01/23/2020

Medical urgency for kidney candidates is virtually never an emergency. Hence granting medical urgency status should be done prospectively, after the transplant center provides appropriate documentation, not retrospectively as proposed. Similarly, allowing centers 7 days to provide documentation is inappropriate for an issue that has typically been progressing over a prolonged period of time. In our DSA with 5 centers performing pediatric kidney transplants, we have never had an instance of inability to receive dialysis documented over the past 15 years. We have provided medical urgency for only a single instance, a heart-kidney recipient who could not receive the allocated kidney when a small tumor was identified pre-kidney and post-heart transplant. I strongly feel that retrospective review allows the potential for misuse of the status while providing no gain, given the rarity of true medical urgency for kidney transplantation.

Hans Albin Gritsch | 01/30/2020

The waiting time for a renal transplant can exceed 10 years at our hospital. We currently have 10 kidney transplant programs in the DSA. A policy for medically urgent needs has allowed some complex patients to have the opportunity to have a life saving transplant. I support the proposed policy and would suggest that two independent vascular surgeons review the dialysis options and write a supporting letter. There may be exceptions to this rule if it would be an undue burden to the patient. I also support exceptions to the 250 nm rule if this would prevent access to transplantation within a reasonable time for a particular patient.

OPTN Region 4 | 02/08/2020

Strongly support (7), Support (18), Neutral/Abstain (0), Oppose (1), Strongly Oppose (0) Comments: Region 4 supported this proposal. Although there was no clear agreement on where medically urgent candidates should fall in the classifications, there was some support for expanding priority for these candidates to include organs from any ABO compatible donor and giving them top priority on the match. Members encouraged the committee to collect data on the types of candidates requesting medical urgency to determine outcomes (highly sensitized, >1 transplants, etc.). There was also some concern that the “other” category could be abused and it will be very important to review these cases in a timely manner.

Anonymous | 02/10/2020

Unless you agree to allow potential donors to determine which georgraphical area(s) can receive their organs, I will pull my name off of the national donor list. I do not want my liver, kidneys, pancreas, etc going to a patient in another geographical area of the country. The risk of organ death is too high when they have to be sent that far. I am strong advocate of organ transplantation, but my area's transplant centers work very hard to develop a strong donor base. They should not have to be soliciting organs for other areas of the country. You risk losing many donors because of this policy.

OPTN Region 6 | 02/18/2020

Strongly support (0), Support (12), Neutral/Abstain (1), Oppose (2), Strongly Oppose (0) The region generally supported the proposal. For donors with KDPI greater than 85%, all national medically urgent patients should receive priority, not just the medically urgent patients inside the 250 NM circle. Documentation for qualifying patients is important, and the region supports sign off from the patient’s transplant surgeon and nephrologist. A member asked about the outcomes of medically urgent patients, and expressed that we need to track outcomes in this patient population so that we know that we are overall making good use of a scarce resource.

OPTN Region 8 | 02/18/2020

Kidney Transplantation Committee: Addressing Medically Urgent Candidates in New Kidney Allocation Policy • Review should be prospective to avoid a sudden increase in medically urgent transplants and to protect the integrity of the classification, consider a NLRB model • The definition needs to be more specific • It will be important to monitor the data to ensure the best utility of these kidneys • You can tell someone is headed toward a lack of access ahead of time which allows for prospective review Vote on proposal as written: 3 Strongly Support, 7 Support, 3 Neutral/Abstain, 7 Oppose, 0 Strongly Oppose Vote on support for a prospective review process: 20 Yes, 0 No

Hans Gritsch | 02/19/2020

I support the creation of a medically urgent category for kidney transplant candidates who have very limited dialysis access. We have done this locally for many years and have not seen abuse of the system. I am in favor of documentation that all readily available dialysis options have been exhausted, but would not require that the patient have either transhepatic or transcaval catheters. This should be documented by two independent vascular surgeons. The documents should be reviewed in a timely fashion by select members of the UNOS Kidney committee. The use of this options by transplant centers should be tracked and audited if necessary. The geographic distance from the donor to the recipient hospital should be consistent with the newly adopted allocation policy.

Region 5 | 02/21/2020

Strongly support (3), Support (24), Neutral/Abstain (0), Oppose (4), Strongly Oppose (0) Comments (include discussion during breakouts and general session): Region 5 supported this proposal and discussed documentation requirements and how these cases would and/or should be reviewed and monitored. • Required documentation should be specific and address all of the requirements, not just a progress note • Retrospective review, what happens if the retrospective review happens, the urgency is not valid, but the patient is already transplanted? • A gaming concern was raised • Commenter stated that they document two consultations on vascular access and this would be good supporting documentation • Comment was made regarding the consequences of improper use • Commenter stated whether there should be someone outside the institution to validate loss of access • Commenter stated the need for a templated application, and that centers need to work through it methodically. Further commented that liver Status 1A is retrospective and is not worried about consequences of misuse. Final comment was pertaining to whether the transhepatic and translumbar IVC catheters may be excessive if other vascular access has been exhausted/contraindicated. • What happens if the patient gets listed and transplanted and they find it was not sufficient? Would it be a subcommittee? Could you have a designated person do a prospective review? • There are a lot of requests for medical urgency, we always have our patients get two vascular consults

Adam Frank | 02/27/2020

For many years now, the majority of patients awaiting a deceased donor kidney transplant will not get transplant and are more likely to be delisted for loss of transplant candidacy or die. This speaks to the severe shortage of kidneys. This proposal allows a subset of candidates to jump the line. This must be carefully monitored and I would favor this not being offered except for the very young (the pediatric patients and the EPTS>20 group) which already have carve outs in the current system.