Improving dual kidney allocation
Sponsoring Committee: Kidney Transplantation
Strategic Goal: Increase the number of transplants
Effective date: September 5, 2019
Policy notice (PDF - updated with technical correction on 3/15/2019)
Kidney Committee Board briefing paper- dual (PDF - 619 K; 12/2017)
By the conclusion of 2016, a record-setting 12,245 deceased donor kidneys transplants were performed nationwide.1 However, there were still 98,962 candidates waiting for a kidney transplant.2 One strategy to increase the number of kidney transplants is to reduce the number of discards of high Kidney Donor Profile Index (KDPI) kidneys through double kidney transplantation. The OPTN/UNOS Kidney Transplantation Committee (“the Committee”) is proposing amendments to OPTN policy to improve dual kidney allocation. Dual transplants and high KDPI transplants are disproportionately performed more often in older recipients; expanding the use of dual transplantation of high KDPI kidneys could serve to counterbalance the modest decline in access for older patients post-KAS.3 Amending current OPTN policy and enhancing programming could increase usage of high KDPI kidneys that are currently at increased risk for discard.
Members say that current policy is ambiguous, out-of-date, and does not enable them to identify and allocate dual kidneys in a timely manner. As a result, dual kidneys are often offered only after the wait list has been exhausted, leading to longer cold ischemia. Transplant programs, especially those with high dual transplantation volume, say that they would prefer to receive dual kidney offers earlier (ideally before organ recovery), to allow time for logistical planning and to minimize cold ischemia. Likewise, OPOs tell us that they favor pre-recovery criteria to facilitate allocation more efficiently.
The Committee distributed a concept paper during the spring 2017 public comment period in order to seek public input on three proposed concepts that aim to address the above problems. This initial round of public comment revealed support for a modification to the allocation tables that incorporate dual kidney allocation to centers that have opted in to receive these offers. The Committee now seeks additional community feedback on the selected policy solution.
1 “Data – OPTN," United Network for Organ Sharing, https://optn.transplant.hrsa.gov/data/. Accessed December 14, 2016.
3 Stewart, Darren E. & A. Kucheryavaya, Beck, J. One Year Evaluation of the New National Kidney Allocation System (KAS). OPTN/UNOS Monitoring Plan Final report. Prepared for the OPTN KAS Implementation Committee of the Kidney Transplantation Committee, April 18, 2016.
- Enterprise: UNOS IT effort to implement both dual kidney and en bloc proposals simultaneously is 6,510 hours
- Architecture work is an additional 2,200 hours.
- Implementation effort includes waitlist allocation changes and instructional offering.
- UNOS ongoing IT effort is small.
- Immediate implementation upon programming for members
- Minimal implementation and ongoing impact for members
- Potential additional transportation cost to ship kidneys normally discarded; depends on volume.
IT Implementation effort to modify waitlist and allocation is substantial. If this proposal and the en bloc proposal are approved, IT would implement these simultaneously over approximately 6,510 hours. If this proposal is implemented alone, IT hours would be slightly less, at just under 5,000 hours.
Architecture work to separate kidney allocation logic from other organs is estimated at 2,200 hours, in addition to IT hours estimated. Architecture work assumes the en bloc and dual kidneys proposals are executing together.
Instructional Innovations will provide an educational offering to complement the modifications.
Hospital: This proposal requires minimal additional staff time to implement and maintain. It can be implemented immediately. Some staff time to acquire additional patient information upon listing may be necessary. If organs that are normally turned down are used, then an overall increase in transportation cost may result, but this can be claimed for reimbursement.
OPO: Minimal staff training is needed to adjust for the change. It is possible that the cost of pumping and shipping kidneys (also impacts hospital) may increase, but any additional cost may be offset by a reduction in discarded kidneys.
Lab: No impact.