Guidance to increase nonA1 and nonA1B kidneys for type B candidates

Proposal Overview

Status: Implemented

Sponsoring Committee: Minority Affairs

Strategic Goal: Provide equity in access to transplants

Guidance: Increase non A1 and non A1B kidneys for type B candidates (PDF - 317 K; 12/2017)

Minority Affairs Committee Board briefing paper (PDF - 617 K; 12/2017)

Blood type B candidates, a blood group more common in underrepresented minorities, have longer kidney waiting times. In December 2014, the new Kidney Allocation System (KAS) became effective, including Policy 8.5.D: Allocation of Kidneys by Blood Type, which allows for blood types A, non-A1 and AB, non-A1B kidneys to be transplanted to blood type B recipients who meet certain criteria.¹

Allocation of deceased donor kidneys from blood group A, non-A1 and AB, non-A1B to blood group B kidney recipients has improved transplant rates among disadvantaged blood group B patients with equivalent long-term graft outcomes compared to blood type compatible transplants.^{2, 3} However, the 18 month KAS post-implementation data analysis revealed that an overwhelming majority of transplant programs (82 percent) do not perform any non-A1/non-A1B (A2/A2B) transplants and that overall transplant programs have not taken advantage of this policy change, which provides greater access to deceased donor kidneys for disadvantaged blood group B candidates.⁴ Further, a 2016 OPTN/UNOS Minority Affairs Committee (MAC) survey to all active U.S. kidney transplant programs revealed that many programs cited difficulty in establishing a protocol for patient enrollment as the major barrier to performing these transplants. Specifically, the transplant programs identified the following obstacles when developing the required protocols to participate in non-A1 transplants:

Difficulty establishing titer thresholds (32 percent)
Difficulty developing an informed consent policy (21 percent)
Difficulty determining patient eligibility (18 percent)

OPTN/UNOS policy allows each transplant program to develop and implement protocols for determining candidate eligibility, but many established programs follow similar practices for protocol.

Based on the survey findings, these best practices are offered in a guidance document as an effort to increase the number of kidney transplant programs that perform non-A1/non-A1B (A2/A2B) transplants. An increase in the number of programs using this provision can increase equity in access to transplants for disadvantaged blood group B candidates, due to a greater number of potential donor matches.

¹ OPTN Policies, Section 8.5D: Allocations of Kidney by Blood Type
² Forbes RC, Feurer ID, Shaffer D. A2 incompatible kidney transplantation does not adversely affect graft or patient survival. Clin Transplant 2016: 30:589-597
³ Williams WW, Cherikh WS, Young CJ et al. First report on the OPTN national variance: Allocation of A2/A2B deceased donor kidneys to blood group B increases minority transplantation. AJT 2015; 15:3134-3142.
⁴ Aeder, Mark. The New Kidney Allocation System (KAS): The First 18 Months. Prepared for OPTN Minority Affairs In-Person Meeting, September 20, 2016.

Also called A2/A2B donor kidneys

Read the full proposal (PDF - 835 K)

Feedback requested

The Committee requests the following feedback:

Are there any additional resources that would be helpful in non-A1/non-A1B (A2/A2B) provision implementation at your center?
Do you think developing a non-A1/non-A1B (A2/A2B) protocol will increase the number of kidney transplants performed at your center?
What is the burden, including financial or staff burden, to programs or labs to implement the guidance?

Impact points

VERY SMALL: UNOS implementation effort to create educational offering to complement guidance
Minimal implementation impact for members: Hospital and lab staff time to develop protocol and to confirm patient eligibility
Minimal ongoing impact: Labs may require additional staff hours if volume of titer testing increases
Ongoing cost dependent on change in testing volume
1-3 months to implement for members
Guidance documents do not contain new member requirements. However, the assumption in estimating fiscal impact is the members will follow guidelines

Project size/complexity

UNOS

Implementation and ongoing effort is very small.

Instructional innovations will produce an educational offering to complement the guidance.

Research will provide ongoing results on the impact of the guidance.

MEMBER

Hospital: Staff time to develop protocol, patient consent, and to confirm eligibility is required to implement. It is estimated that implementation occurs in one to three months.

Ongoing costs can include staff time and resources to administer titer retesting. Additionally, centers are concerned with the potential for a greater number of post-transplant complications, if they do not already consider these blood types compatible. If volume increases substantially, this could total several thousand additional dollars.

If labs and hospitals are not nearby, additional courier costs may result along with an increase in titer testing for blood type B candidates. There should already be a courier arrangement in place if substantial geographic distance exists, however.

Lab: There should be no additional cost if labs are already performing the ABO cross-matching in the guidance. Some staff time may be necessary to develop protocol with hospitals not currently participating in the provision. Ongoing increase in staff time, due to higher testing volume, may result if titer retest volume increases substantially. All costs are reimbursable, but may cause a strain on staff resources.

OPO: No impact.