Improving en bloc kidney allocation 2View comments
Sponsoring Committee: Kidney Transplantation
Strategic Goal: Increase the number of transplants
Effective date: September 5, 2019
Policy notice (PDF - 745 K; 6/2019)
Note:The policy notice was originally published 12/2017, and revised in 6/2019.
Kidney Committee Board briefing paper - en bloc (PDF - 988 K; 12/2017)
Kidney transplantation is the preferred treatment for end stage renal disease (ESRD), yet demand for kidneys far exceeds supply. One strategy to increase the donor pool is to use kidneys from small, pediatric donors. However, programs may be reluctant to transplant single kidneys from small pediatric donors due to technical challenges, which may result in inferior outcomes.
To mitigate the complications associated with transplanting kidneys from small pediatric donors singly, both kidneys, including the vena cava and aorta, can be transplanted en bloc into a single recipient. However, there are currently several challenges to allocating en bloc kidneys:
- There is currently no OPTN policy regarding allocation of en bloc kidneys
- The Kidney Donor Profile Index (KDPI) programmed into DonorNet® doesn’t consider how kidneys will be used (en bloc or single) or acknowledge the improved function of en bloc kidneys, which could screen medically suitable candidates off the match run. In addition, there are other programming limitations that make en bloc kidney allocation a challenge
The proposed policy resolves these problems by providing explicit direction to organ procurement organizations (OPOs) on when to allocate en bloc kidneys. The policy includes donor criteria regarding the type of kidneys that can be allocated en bloc and mandates that programs must indicate in WaitListSM that they accept en bloc kidneys, thus expediting placement of en bloc kidneys to programs that will transplant them. In addition, the Kidney Transplantation Committee (Committee) proposes masking the KDPI score for en bloc kidney offers to prevent potentially eligible candidates from being screened off the match run for kidneys from high KDPI donors.
This proposal aligns with three OPTN strategic goals. First, it should increase the number of transplants by utilizing kidneys previously left unrecovered or discarded. Second, it should improve outcomes for waitlisted kidney candidates and transplant recipients as studies indicate when kidneys from a small pediatric donor are transplanted into a recipient en bloc versus singly, they confer comparable to superior outcomes. In addition, accepting kidneys en bloc may shorten a candidate’s time on the waitlist, conferring not only a survival advantage, but also several other additional benefits. Finally, this proposal should increase efficiency in management of the OPTN as OPOs should no longer have to contact the Organ Center for guidance or assistance in allocating en bloc kidneys.
The proposal has been amended after its first round of public comment. Following the spring 2017 cycle, the Committee voted to remove the provision granting OPOs the option to allocate kidneys from donors weighing between 15 and 25 kg en bloc or as singles and added a provision mandating en bloc allocation for en bloc kidneys from donors weighing 20kg or less. Following the June 2017 Board of Directors meeting, the Committee lowered the mandatory en bloc allocation donor weight threshold to 18kg in response to feedback.
Read the full proposal (PDF - 784 K)
Does the community support the reduced mandatory en bloc allocation donor weight threshold of 18 kg? The provision allowing surgeons to split them if they determine upon receipt that they can be transplanted as singles would remain.
Members are asked to comment on both the immediate and long term budgetary impact of resources that may be required if this proposal is approved. This information assists the Board in considering the proposal and its impact on the community.
- 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.
- Immediate member implementation upon programming
- Increased cost at hospitals may result from increase in en bloc transportation and recovery time
- Efficiencies in OPO administrative staff time on allocation may result
IT Implementation effort to modify waitlist and allocation is substantial. If this proposal and the dual kidney proposal are approved, IT would implement these simultaneously over approximately 6,510 hours. If this proposal is implemented as a single effort, IT hours for en bloc alone would require just under 3,600 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: Minimal time to educate clinical and administrative staff on policy change is needed. Additional travel time or operating room time to obtain and then transplant en bloc kidneys may result in additional cost. Additional costs can be passed to payer. En bloc transplant volume may increase overall. Immediate implementation is possible.
OPO: Minimal time is needed to educate staff. There may even be a decrease in staff time required to allocate organs. The allocation sequence will be clear and efficient because staff will know which kidneys can be recovered en bloc.
Lab: No impact.