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Transplant Centers - National Kidney Registry - Facilitating Living Donor Transplants
Match Offer Selection- The NKR shall select match offers based on the
following scientific and objective criteria:
When adequate time is available, match offers shall be selected to facilitate the most
possible transplants except when difficult to match pairs can be matched. Pair
matching difficulty shall be measured by the pair match power (PMPc) score.
When time is limited (e.g. NDD has a limited timeframe, compatible pair
involvement in a swap, etc.), match offers with the greatest probability to make it
to transplant within the allotted timeframe shall be selected. In these cases priority
shall be given to factors such as:
Donor has already been accepted in the pre-select function.
Cross match has already been completed and is acceptable.
Fast track center (can go from offer to transplant in 3 business days).
When multiple potential match offers yield equal numbers of transplants, in
addition to the considerations outlined in #1 & #2 above, prioritization shall be
Patients with the longest wait times in the NKR system.
Patients at centers with the highest Center Liquidity Contribution.
Ending Chains - The NKR shall end chains according to the following priorities:
To former NKR Non-Directed Donors (NDDs) in need of a kidney transplant.
To a recipient whose donor has donated and the recipient does not have a kidney such as
when an intended donor becomes ill, an out of sequence swap is executed or when advance
donation with informed consent takes place.
To CHIP (Children and High cPRA Patients) candidates.
When multiple CHIPs can end the same chain,
prioritization shall be given to:
Children > 80% NKR cPRA.
Adults > 80% NKR cPRA.
Children < 80% NKR cPRA.
Adults < 80% NKR cPRA.
Photographing Damaged or Abnormal Kidneys - The NKR suggests taking digital photographs after nephrectomy and before transplant to ensure quality.
Once a kidney is removed from a donor, if there are no abnormalities, digital pictures
of the kidney are encouraged, but not required.
If there is any damage to the kidney or any other abnormalities not already communicated
to the recipient surgeon, the donor surgeon is required
to email or text pictures of the kidney, packaging or box to the recipient surgeon
within 30 minutes after kidney removal.
If the kidney is declined by the receiving center, the receiving center must take and
store pictures of the kidney that include any abnormalities.
Upon receipt of the returned kidney, the donor center must take and store pictures of
the kidney, packaging or box that include any abnormalities.
Managing Real-Time Swap Failures - A real-time swap failure occurs when a swap fails after one or more donor surgeries have
begun. When a swap fails in real-time, NKR shall:
First attempt to cancel or reschedule the swap.
If any of the donor surgeries cannot be aborted, then the NKR Member Centers shall
proceed with the swap and the NKR shall immediately work to end a chain (utilizing a
bridge donor or a non-directed donor) to the patient in the failed swap that did not
receive a kidney.
The center caring for the patient that did not get a kidney must remove all restrictive
preferences and accept all viable donors via the donor pre-select function unless the
center determines that it is in the patient's best interest (e.g. pre-emptive
transplant) to wait longer by declining viable potential donors in order to get a better
If the patient that did not get a kidney is hard to match (e.g. NKR cPRA > 80%), the NKR
may not be able to find a compatible donor for that patient. This risk must be disclosed
in the Member Center's informed consent documentation that is signed by the patient and
In the calculation of "net chains started", the donor center is accountable for the
The donor center shall cover all costs related to the donor surgery and donor care.
If the real-time swap failure was caused by the recipient center's decline of a
The kidney will be immediately shipped back to the donor center using the
fastest method of transportation available, to minimize
cold ischemic time, for transplant into a wait-listed patient.
If the kidney is utilized by the donor center and functions adequately:
The center declining the kidney will be responsible for all shipping and
logistics costs (estimated at between $10,000 - $100,000) and;
The recipient surgeon will be required to review the case with the
If the kidney is not utilized by the donor center or does not function
The donor center will be responsible for all shipping and logistics
costs (estimated at between $10,000 - $100,000) and;
The donor surgeon will be required to review the case with the Surgical
If there is ambiguity regarding the adequate function of the declined kidney,
the Surgical Committee will make a determination based
on medical data provided to the committee by the transplanting center one month
after the transplant.
Member Center Requirements
NKR Service Contract is current.
Donor Center Agreement is current.
Recipient Center Agreement is current.
Member Center's Earliest Organ Pickup Time is 11:00 or earlier.
Member Center's Latest Organ Pickup Time is 18:00 or later.
Member Center's 30 Day Moving Average Preselect % is at or above 95%.
Member Center's Data Compliance is at or above 99%.
Member Centers do not reverse pre-selects after a match is offered.
All Routine Member Center Requirements are assessed at month end.
Centers shall share all relevant information to ensure the best possible outcomes for
all swap participants.
Centers shall act with the utmost spirit of cooperation to achieve the greatest number
of successful transplants across all member centers.
Centers shall ensure all information entered into the NKR web site is updated and
Centers shall ensure swap participants are ready to go to surgery once they are
activated in the NKR system.
If a pair becomes unavailable to participate in a swap (e.g. recipient sick), that pair
must be immediately deactivated in the NKR system.
If a donor is travelling internationally or expects to be unavailable for blood draws
for a period of a week or more, they must be deactivated in the NKR system until they
are once again available for a blood draw.
Centers shall enter accurate post-transplant data so that research can be conducted on
Centers shall not contact another center's donor, recipient or lab for any purpose.
Centers shall immediately request an exploratory cross match if there is a reasonable
chance of an unacceptable cross match with a potential donor.
Centers shall provide the NKR, upon request, a root cause and corrective action plan
within one business day of the request.
Centers shall, prior to a swap kickoff, run back-up lists for both sides of the swap in
the event that a donor kidney removed at your center cannot be shipped and must be used
at your center or your center receives a kidney and your recipient is unable to go to
Centers must complete the NKR organ packaging checklist and ensure a copy of the organ
packaging checklist is shipped with the organ in order to comply with CMS regulations.
Centers involved in swaps shall have proper kidney packaging supplies on hand and a
trained organ preservationist on call to pack the kidney in case the kidney is
shipped back to the donor center.
Centers shall request information using the "REQUEST DONOR INFO" feature. The Donor
Center must enter the requested information into the donor profile and notify the
requesting center that the requested information has been added to the donor profile
within 1 business day of receipt of the request.
Donor center must register the donor and obtain a UNOS Donor ID number.
Centers shall have laparoscopic donor surgical capability.
Centers shall communicate to all donors that the expected turn-around time for a blood
draw request is one business day.
Centers should perform a wellness check on both the donor and recipient within 24 hours
of scheduled pre-op. The minimal requirement for the wellness check is a phone call to
the donor and recipient confirming they are healthy and ready to move forward with the
Centers are encouraged to place recipients on hold for deceased donor transplants, once
cross matching commences.
Primary and backup coordinators shall:
Be identified with cell numbers entered on the web site
Respond same day (email or phone) during regular business hours
Be available 24x7 the day before, and the day of a swap
Be available for conference calls (e.g. logistic calls, kickoff calls, etc.)
If an Exchange Coordinator becomes aware of a situation that
puts the swap at risk he/she must immediately send an email to Member Services with
notification of the situation and then contact the NKR Swap Manager via phone. If the
Swap Manager cannot be reached via phone the Exchange Coordinator must alert their NKR
Center Liaison or any other member of the NKR staff.
If a center experiences an issue that is reported in the quarterly swap failure report,
the primary or backup coordinators must attend the National Coordinator call to review
the root cause and corrective action related to the swap failure.
Shall be available for surgery upon three weeks advance notice.
The donor surgeon must call the recipient surgeon within an hour after completion of
the donor nephrectomy.
If the donor surgery went well and there are no concerns, and the
recipient surgeon is not available, a voice mail will suffice. If there are
concerns, a second attempt should be made to reach the recipient surgeon. If the
second attempt fails, then the recipient center coordinator must be contacted to
pass along the information. The surgeons must speak when both are available.
When a match offer is received, the following communications shall take place:
Center first contacts the donor to ensure availability for surgery and no
If the donor is available, then the center contacts the potential recipient to
ensure availability and no medical changes.
If both the donor and the recipient are available for surgery and report no
medical changes, the center accepts the match offer.
Centers shall respond to match offers by the match offer deadline which is generally
within one business day of the offer.
When a match offer is accepted, the pair must be immediately deactivated in all other
exchange programs, including internal programs.
When a match offer is accepted, the recipient's chart must be reviewed for updates and
creatinine must be immediately rechecked for predialysis patients.
HLA, Cross Matching & Serology Tests
Centers shall accurately enter all donor and recipient antigens, and all recipient
Centers shall perform two ABO typing's for donors, including sub typing where
appropriate, before they are activated in the NKR system.
Centers shall conduct antibody screenings every 90 days for sensitized patients and
update the avoids appropriately.
When cross matching commences, donor medical records shall be immediately shared with
the recipient center. If the recipient center needs CTA film, the recipient center must
request the film within 1 business day of the commence XM notification.
Donor serology testing must be completed prior to the
surgery date to insure the donor can proceed.
If a center reports an unacceptable cross match, the lab director shall review the root
cause and corrective action plan on the National Lab Director call.
The NKR uses three types of Cross Matches:
Exploratory cross matches are requested by a recipient center prior to a match
offer to confirm a donor is compatible with a sensitized recipient.
Screening cross matches are required once all match offers in a swap are
accepted; this cross match will be commenced by NKR.
Final cross matches are requested by the recipient center 1-2 weeks prior to
The following cross matching procedures are utilized according to the timeframes in the
Donor center draws and ships donor blood to the recipient center/lab.
Donor blood tubes that are shipped to the recipient center include donor name,
date of birth, social security number, date specimen drawn and initials of
technician drawing the blood.
Donor center notifies recipient center when to expect blood and provides the
package tracking number.
Packaging supplies include:
Red biohazard bag inside organ box.
Clear plastic bag with ice inside a Styrofoam container.
Triple barrier packaged kidney (one of which is jar) - all sterile.
Labeling attached to kidney bag.
Kidney box must include the following:
A UNOS label filled out according to UNOS standards on the outside of the box.
NKR supplied GPS Device, unless the kidney is travelling via On Board Courier.
NKR supplied Human Organ stickers affixed to all 6 sides of the
box before other labels are applied so that other labels are fully visible, NKR Stickers will
be supplied in the GPS box.
Destination mailing address on the outside of the box (recipient center).
Return address on the outside of the box (donor center).
Two ABO verifications each for donor and recipient (if ABO on crossmatch that
may considered as first ABO for donor and recipient).
Crossmatch result of the donor and recipient.
Kidney anatomy (aka Renal Data Sheet).
Name and DOB of Recipient.
Teidi Donor Registration Page: Please 'print screen' this page (page displays
Donor Name, DOB, Donor UNOS ID Number).
Donor blood tubes per recipient center request.
Copy of the completed NKR packaging checklist.
Kidney must be 100% covered in ice.
It is the responsibility of the recipient center coordinator to monitor
the GPS device.
Donor Centers will receive a GPS device, from NKR approximately 1-5
business days before donor surgery. The device requires no activation.
The GPS device must be packed on top of the ice or inserted between the shipping containers, unless
an On Board Courier is transporting the kidney.
If the kidney is being transported via On Board Courier:
The GPS device should be given to the driver, not packed in the box with
A letter should be given to the courier explaining what is in the box,
as well as instructions not to open the box. Click
here for a sample
Coordinators at both the donor and recipient centers will receive periodic
alerts to their cell phone and Email, giving the location of the GPS beacon. The device
will give a N/A reading once airborne at an altitude of approximately 5,000 feet and
higher, it will take approximately 30 minutes after take-off to give the N/A reading.
The coordinator must contact the swap manager immediately if there are any
inconsistencies between the GPS readings and logistics plan.
Recipient Centers will receive pre-paid return packaging from NKR for the return
of the GPS.
The GPS device must be sent back to NKR within one business day of recipient surgery.
In addition to periodic alerts the device can be tracked via the internet,
instructions on accessing the GPS tracking website are listed below.
Contact your NKR liaison to acquire user name and password.
Enter the username and password you were given and click login.
On the right side of the screen highlight the device you are looking to
listed under "Map View", once highlighted click "show selected" button.
To view in Google Earth wait for map to open and in top right of map
Google Earth Format".
NKR Member Center Guidelines
Living Donor Evaluation- The
purpose of the evaluation and consent of the living donor is to maintain the highest
degree of safety and transparency for the living donor. As a baseline, the
Guidelines and the OPTN standards will be used for donor evaluations. Donor evaluations
must be completed before a donor can be activated in the NKR.
The donor center evaluation policies should be followed by the donor center and not be
directed by the recipient center since the donor center is responsible for donor care. The
receiving center may ask for additional testing to clarify issues related to the quality of
the kidney or to ensure there is minimal risk of infectious disease transmission. Requests
for additional donor testing should be made immediately upon cross commencement in order to
avoid late stage donor declines and failed swaps.
Complete history and physical.
Height, weight, BMI.
BP at two different settings on different days.
General laboratory to assess:
fasting lipids and glucose.
Age appropriate evaluation for cancer.
Donor work-ups must be repeated in their entirety, every 12 months, except for
CT angio, unless the first CT angio was abnormal.
Urinalysis with microscopy.
Urine culture if indicated.
24 hour urine for albumin excretion and creatinine clearance.
Anatomic Testing for anatomy definition.
If a donor GFR reading comes in at or below 85, the center will perform a
nuclear medical GFR test to confirm the donor's GFR is > 80.
If there is > 10% difference in donor kidney size (between the two kidneys)
then the smaller kidney will be offered for donation.
Spot Urine albumin: creatinine ratio measurements may be used instead of 24h
proteinuria at centers that use nuclear medicine GFR measurement. The acceptable
range for urine albumin: creatinine ratio is less than 30 mg/mg.
Chest X-Ray (CXR).
Criteria for high risk donors: (based on history and physical)
Birth or residence in a TB endemic country.
Close contacts of individuals with TB (Household or family members).
Donors who work or have resided in homeless shelters, correctional facilities, nursing homes, or hospitals.
History of IV drug use.
Evidence of granulomas or healed TB on CXR.
For donors meeting the criteria for high risk we recommend Interferon-gamma release assays (IGRAs) or tuberculin skin test (TST).
Recipient center may choose to have additional testing performed at time of match offer acceptance.
Infectious disease screening:
HBsAg, HBcAB, HBsAB.
Depending upon time of year and location associated risk:
West Nile Virus.
Suggested evaluation for donors at risk for metabolic syndrome or diabetes:
Glucose tolerance testing.
If multiple stones or nephrocalcinosis are not evident on CT, an asymptomatic potential
donor with history of a
single stone may be suitable for kidney donation if they have:
No hypercalcuria, hyperuricemia, or metabolic acidosis.
No cystinuria, or hyperoxaluria.
No urinary tract infection.
An asymptomatic potential donor with a current single stone may be suitable if:
The donor meets the criteria shown previously for single stone formers.
The current stone is less than 1.5 cm in size, or potentially removable during
Stone formers who should not donate are those with:
Nephrocalcinosis on x ray or bilateral stone disease.
Stone types with high recurrence rates, and are difficult to prevent.
Post Donation Follow Up and Donor Complications - A post-donation follow-up should follow the policy described in CMS Pub. 100-02, Chapter 11, section 140.9, including:
The UNOS required 6 month, 1 year, 2 year follow-up should not be included in the organ
acquisition cost center or separately billed to Medicare.
Follow-up care rendered by a physician who performed the operation is included in 90 day
global. After 90 days, charges are billable to recipient's Medicare number.
For follow-up care rendered by physician other than operating physician, bill to
recipient's insurance for up to 3 months unless directly related to complications of the
Charges are routed to Organ Acquisition for up to 90 days or up to 6 months if
potentially related to complications.
After these time periods, facility charges may not be allowable on the Medicare Cost
In all of these situations, the donor is not responsible for co-insurance or deductible.
Good Samaritan Donors - A Good Samaritan
Donor is also known as a Non Directed Donor (NDD). They are donors that want to donate to a
stranger and may want to start a chain of transplants. Guidelines for Member Centers working with
Non Directed Donors are as follows:
NDD's should be made aware of their donation options. They can either start a chain
of transplants or donate to a single recipient on the centers waitlist.
If an NDD donates to someone on the center's wait list, the scheduling of
the surgery may be easier for the NDD.
If an NDD starts a chain of transplants, they will generally help more
people get transplants.
It often requires a long wait time for "A" and "AB" blood type NDD's to start a
chain of transplants.
Centers should advise NDDs that NKR will provide donor insurance if they
start a chain through the NKR.
It is the responsibility of the Center to educate the NDD. Centers
should fully explain the donation process to the donor and should let them know what
to expect, before, during and after surgery.
Centers should ensure that the NDD can get appropriate time off from work.
Centers should determine the NDD's availability for surgery and accurately
enter it into the NKR system.
Centers should ensure the NDD is updated on a timely basis regarding where
they are in the workup process, results of all medical tests, when they are
activated in the NKR program and the status of chains that the NDD is facilitating.
The Center should inform the NDD that there may be financial support
available to assist them in the donation process if they qualify. Eligibility
guidelines can be found by clicking on the link to the National Living Donor
Assistance Center website.
Bridge Donors - A bridge donor is any paired donor that donates after their paired recipient
receives a kidney transplant in a swap. The bridge donor serves as a
"bridge" to the next cluster of transplants in a chain and generally has the ability to
be with their friend or family member while they recover from transplant surgery, before
they themselves go through kidney donation surgery. Bridge donor guidelines are as
Bridge donors should be prepared to donate between one week and three months of their
paired recipient's surgery with no significant schedule limitations.
Bridge donors must have no significant medical risks that could prohibit them from
The donor center must be confident that the bridge donor will follow through with
New centers may want to complete at least three exchange transplants prior to
identifying donors as bridge donor candidates.
Member center guidelines for educating and evaluating donors to qualify a bridge
donor candidate should include:
Discussions regarding the possibility of being a bridge donor should begin at
initial donor evaluation and continue throughout the process.
If there is any hesitation with the potential bridge donor, the center should
decline offers to bridge the donor and identify the donor accordingly in the NKR
When asking a donor to bridge, an in-person discussion should occur and include
the donor's support person.
Member centers must maintain frequent contact with bridge donors.
Member centers should advise bridge donor candidates to discuss their commitment
to paired exchange with their employer early in the process and again when they
become a bridge donor.
Member centers must clarify any time constraints with bridge donor candidates
and advise donors of the need for immediate notification of any unexpected
travel plans and availability during that time for blood draws.
Member centers should re-educate donors and reconfirm their availability prior
to accepting the donor for a bridge position in a swap.
Help for Patients without Donors
NKR CHIP Program- The CHIP program helps patients without donors who are either children or are disadvantaged because they are sensitized
Centers may enroll up to 50 candidates in the CHIP program.
The center receiving the kidney shall be determined based on forecasted net chains
started (FNCS) with the objective of managing FNCS by center within a range of -1 to +3.
For the purpose of calculating FNCS, the Member Center that completes the NDD work-up is
the center that receives credit for starting a chain.
Net chains started is the total number of chains that a center starts less the total
number of chains a center ends.
CHIP candidates are patients without donors including children (18 or younger) or
The most likely blood type to find a CHIP match is an "AB" patient, followed by "A" and
"B" blood type patients.
Help for Medicaid/MediCal Patients
Medicaid and MediCal patients- These patients are
typically disadvantaged in paired exchange because these insurance programs will generally not pay for out of state physician's fees which will
block matches with out of state donors. The best opportunity for Medicaid/MediCal patients
is to convert their insurance to Medicare. Below is a conversion guide.
If the patient is on dialysis and has the requisite work history, then Medicare
enrollment is granted based on dialysis prior to transplant.
If the patient is not on dialysis and has the requisite work history, then the center
should assist the patient with the process for Medicare enrollment at the time of
transplant and communicate a billing hold to current payor(s) until Medicare is
effective. Additionally, the donor center must agree to hold billing for all
professional fees until recipient's Medicare policy goes into effect (a billing hold is
better than billing and reimbursing the current payer and then rebilling Medicare).
Centers must assist patients with obtaining documentation of Medicare entitlement
so that the center can complete a CMS Form 2728 Medical Evidence Report (MER) in order
to implement Medicare coverage.
The recipient's Center must provide a completed CMS 2728 Form to the donor center upon
match offer acceptance.
Medicare entitlement should always be confirmed prior to transplantation so that the
patient is aware of any potential out of pocket expenses, the need to choose RX coverage
and other related financial issues.
Many centers have unsensitized "O" patients with an incompatible "A", "B" or "AB" donor that have been waiting a long time for a match offer. If your patient has another donor, you can DOUBLE their odds of receiving a match offer by entering the second donor into NKR.
One criterion that the Medical Board prioritized in the Match Offer Selection Policy was wait time. Wait time is accrued for days that the pair is "exportable" and is NOT based on registration date. The sooner a center can make a pair exportable and the longer the pair remains exportable, the more wait time the pair will accrue.
Abundant A2 donors - If you have an “O” recipient pair, consider accepting an A2 donor – there are abundant (16) unmatched A2 donors in the system and only 3 of those A2 PDs are paired with highly sensitized patients.
Many donors are declined on anatomy, blocking potential matches. In some cases, these declines can be overcome by offering the other kidney which may not exhibit complex anatomy. Two new options have been added to the "kidney to be donated" field in the donor profile: 1) left but right available and 2) right but left available. If the kidney that you are offering has complex anatomy and the other kidney can be offered, you can overcome anatomy declines and help get your patient get transplanted.
Compatible pairs: When considering which compatible pairs are appropriate for paired exchange, look for blood type combinations that will match quickly. An A, B or AB patient with a compatible O donor will find a match immediately while other compatible pair blood type combinations (e.g. O to O, A to A, etc.) may not be matched as quickly and therefor may not be good candidates for paired exchange because of the longer wait times.
More centers should consider using charter flights to ship kidneys when no direct flights are available. For a mere 18% average increase in costs over an “on board courier” transit times are reduced from an average of 11 hours to less than 5 hours (see attached analysis). Charter flights reduce CIT and help limit late nights for your surgical teams.
If you have a patient that is has not received a match offer and you are wondering if there is an issue with the paired donor, that is causing centers to decline the donor, take a look at the new “declines” tab in the donor profile. This tab provides an accounting of the donor declines and the reasons for each decline.
The NKR can improve the donor-recipient match for compatible pairs which can improve patient outcomes while facilitating transplants for many other incompatible pairs. Click on the following link to learn which compatible pairs should consider entering a swap to get a better match and the benefits to the patient of a better match. http://www.kidneyregistry.org/compatible_pairs.php
The median wait time for pairs with a pair match power (PMPc) score greater than 100 is less than 2 months - so make sure these pairs are completely ready to go to surgery before they are activated in the system.
If you have an A, B or AB blood type patient with a cPRA < 80% then this patient will be easy to match and therefor you should use a low MFI cutoff (e.g. 1000) for setting avoids so that your patient is matched with a donor that yields a clean cross match.
If your center has a forecasted “net chains started” number of +1 or more, your center may be able to immediately receive a match offer if you enter more CHIP candidates. We generally have several “A” blood type NDDs that are not matching anyone and may match a CHIP that you enter. Each center can enter up to 50 CHIPs.
Adequate Surgical Capacity Will Help Your Patients Get Matched & Transplanted - NDDs and compatible pairs often have tight timeframes for surgery, limiting swap scheduling options. Many patients that are matched in FAST TRACK swaps are losing out on transplant opportunities due to the lack of surgical capacity at some centers. These centers can get more patients transplanted by increasing surgical capacity. Centers are increasing surgical capacity by 1) coordinating surgeon vacation/travel schedules to ensure coverage on NKR target swap days which are Tuesday, Wednesday & Thursday 2) cross training donor and recipient surgeons and 3) hiring more surgeons.
How quickly should you implement Advanced Matching Strategies - If your difficult to match pair does not get an offer in the first month, move to advanced matching strategies. Don’t wait. With NKR’s large pool and rapid “churn” of the pool, your patient will be exposed to matches with most donors in the pool in the first 30 days.