Medical Board Policies
- 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 patients involved in real-time swap failures where the donor has donated but the patient did not get a kidney.
- To ADP patients who are ready for a transplant.
- To CHIPs at Member Centers with Net Chains Started (NCS) > 0 or Partner Centers.
- To NKR Member Centers with NCS > 0 who have declined 3 or fewer chain end offers per chain start, in the past 12 months.
- To NKR Partner Centers
- 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 match.
- 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 the donor.
- In the calculation of "net chains started", the donor center is accountable for the chain break.
- 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 Surgical Committee.
- 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 Committee.
- 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.
- Advanced Donation Program - The Advanced Donation Program (ADP) is a paired exchange separated in time. This program allows medically and psychosocially acceptable Donors to donate their kidney before their Intended Recipient receives a kidney at the end of a chain.
- An ADP donor may identify one intended recipient unless multiple immediate family members have renal function impairment.
- An ADP Recipient may have up to five ADP Donors
- No additional Intended Recipients can be added after the ADP Donor signs the Informed Consent document.
- When an ADP Donor has multiple Intended Recipients, the first appropriate candidate for transplant will receive the ADP Kidney.
- The ADP donor and Intended Recipient can be at different centers but those centers must both be ADP participating centers.
- Intended Recipients must be a kidney transplant recipient or currently have, or be expected to have, some form of renal function impairment.
- An ADP donor that starts a chain does not increase a Member Center’s Net Chains Started score.
- Member Center Suspension - The NKR reserves the right to suspend Member Centers from inclusion in match runs if the Member Center is deemed to have introduced safety risks or is in violation of Member Center Requirements. Suspension shall continue until appropriate corrective action plans have been submitted to, and approved by, the Medical Board. Should the Member Center wish to present the corrective action plan to the Medical Board, a conference call with the Medical Board will be scheduled.
Member Center Requirements
- Member Centers shall not have forecasted net chains started less than 0.
- 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.
- Member Centers shall have O/R availability to accommodate Tuesday, Wednesday, or Thursday surgery dates with three weeks advance notice.
- Member Centers shall not cause avoidable swap failures and each avoidable swap failure will be counted as outside of the routine MCRs for 3 consecutive months.
- Member Centers must accept cryo samples for Exploratory & Screening XMs.
- Member Centers must report cryo XM results by 15:00 ET on the second business day after receiving the sample.
- 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 accurate.
- Centers shall have cryo preserved cells on hand for all paired donors.
- Centers shall have CT scans and donor charts uploaded to the NKR system for all paired donors.
- 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 patient outcomes.
- 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 surgery.
- 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 scheduled surgery.
- Centers are encouraged to place recipients on hold for deceased donor transplants, once cross matching commences.
- Recipient Centers shall email a case report within 48 hours to NKR and the donor center when a swap kidney is NOT transplanted into the intended recipient such as when a kidney is discarded, when a kidney is transplanted into a patient other than the intended recipient, etc. The case report shall include all information needed to satisfy the donor center's regulatory reporting requirements.
- When arranging a loop swap (no NDD or BD), all donor surgeries shall be scheduled on the same day and if a red-eye flight is used in the loop, the patient receiving the kidney from the red-eye flight will be scheduled for surgery the day following the donor surgeries.
- Member Center's Earliest Organ Pickup Time is 11:00 or earlier.
- Member Center's Latest Organ Pickup Time is 18:00 or later.
- 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.)
- Monitor the GPS beacon for incoming shipped kidneys as outlined in the GPS Tracking section.
- 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.
- Primary and backup coordinators shall:
- Donor and recipient surgeons at a Member Center shall proactively organize their schedules to ensure surgical capacity is available for KPD procedures on Tuesdays, Wednesdays, and Thursdays with 3 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.
- Match Offers
- When a match offer is received, the following communications shall take place:
- Center first contacts the donor to ensure availability for surgery and no medical changes.
- 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.
- Any known potential swap risk must be communicated to NKR immediately via email and reiterated on the logistics and kickoff calls.
- When a match offer is received, the following communications shall take place:
- HLA, Cross Matching & Serology Tests
- Centers shall accurately enter all donor and recipient antigens, and all recipient avoids.
- Centers shall perform two ABO typing's for donors, including sub typing where appropriate, before they are activated in the NKR system.
- When new pairs are first made exportable, the antibody screenings used to determine the avoids shall be current (within 30 days).
- Centers shall conduct antibody screenings every 90 days for sensitized patients and update the avoids appropriately.
- Recipient centers are expected to report XM results for Cryo preserved samples no later than the next business day following receipt of the cryo preserved NUCS.
- When centers receive a potential match email centers shall record clearance of potential matches according to the following procedure:
- When cross matching and donor record review commences:
- The Donor Center shall have ready in advance, digitized donor records (Charts) available for immediate secure email or fax transmittal to the recipient center within 24 hours of the commence XM donor and record review notification.
- The Donor Center shall ship a CD of the donor's CT scan, via overnight delivery, the same day as the commence XM donor record review notification is received. If the commence XM notification arrives late in the day, the CD may be shipped out the following day
- 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 surgery (cryo preserved samples cannot be used for Final cross matches).
- When fresh blood is used, 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 are labeled according to the instructions.
- Recipient center receives the blood, performs the cross match and records the results on the NKR web site.
- When cryo preserved NUCS are used, the following cross matching procedures are utilized according to the timeframes in the flowchart below:
- Donor center ships cryo preserved NUCS to the recipient center/lab.
- Cryo preserved NUCS are labeled according to the instructions.
- Recipient center receives the NUCS, performs the cross match and records the results on the NKR web site.
- NUCS for exploratory cross matching should only be used for the cross match so that multiple NUCS are not needed. Exploratory cross match testing should not include other testing such as:
- Donor typing
- Multiple Sera
- Multiple Platform
- When using cryo for a screening crossmatch additional NUCS may be requested, if needed, to perform additional tests.
- Shipping Kidneys
- To reduce the inherent shipping risks related to connecting commercial flights, an on board courier must be utilized for all connecting flights.
- Packaging supplies include:
- Organ box
- 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 packaged so that they do not come in contact with the ice.
- Copy of the completed NKR packaging checklist.
- Kidney must be 100% covered in ice.
- GPS Tracking:
- 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 the kidney.
- 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 letter.
- 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. Once airborne at an altitude of approximately 5,000 feet and higher, the Last Known Location will no longer update.
- 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.
- Click here to the NKR tracking software.
- Enter the username and password you were given and click Sigh In.
- On the top of the screen click on the "Mapping" button.
- On the bottom of the screen click on "Scenario" then click the scenario that you would like to view the location of.
- Click on the icon that displays the current location to view a breadcrumb trail of the scenario.
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.
- Basic Evaluation:
- Complete history and physical.
- Height, weight, BMI.
- BP at two different settings on different days.
- General laboratory to assess:
- hematologic status.
- fasting lipids and glucose.
- liver status.
- 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.
- Kidney Evaluation:
- 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.
- It is recommended the donor center have on hand five CD's of CT images for each donor to ensure expedited distribution to a potential recipient center.
- Tuberculosis screening:
- 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:
- HIV 1,2.
- HBsAg, HBcAB, HBsAB.
- Depending upon time of year and location associated risk:
- Trypanosoma cruzi.
- West Nile Virus.
- Suggested evaluation for donors at risk for metabolic syndrome or diabetes:
- Uric acid.
- Glucose tolerance testing.
- Stone Disease:
- 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 the transplant.
- 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.
- 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:
- Basic Evaluation:
- 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 donation.
- 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 Report.
- 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.
- 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.
- 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 donating.
- The donor center must be confident that the bridge donor will follow through with donation.
- 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 donor profile.
- 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.
Donor Protection Program
- Donor Complications - Medical complications that arise as a direct result of the donation are handled as follows:
- If a member center executes the donor protection Addendum they agree to pay for all Uncovered Complications (Donor Complications that are not reimbursable by the recipient insurance, recipient center or recipient) for all donors that undergo donor surgery at the Member Center’ Hospital.
- If a Member Center does not execute the Donor Protection Addendum, they will be billed for donor protection according to the Standard Reimbursements Section to accumulate a fund for uncovered donor complications. The fund is intended to protect donors at centers that have not signed the donor protection addendum. The donor protection fund will be capped at $1 million. Donor claims in excess of the amount in the fund will not be covered.
- If a Member Center records Medicare as a patients primary or secondary insurance and the patient does not complete their Medicare enrollment before the transplant or at the time of transplant, the recipient center shall pay for all Uncovered Complications for the donor who gave a kidney to the patient with the inaccurate Medicare designation.
- Donor Follow Up - Shall be the responsibility of the center that performs the donor nephrectomy.
Medicaid / Medi-Cal to Medicare 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.
Failed crossmatches can be devastating for NKR chains because one failure often affects many potential transplants and transplant programs. On average, a single crossmatch failure in NKR impacts 4 transplants, which affects 4 patients and 4 donors. Crossmatch failures are also costly when tests at other centers are performed for patients who cannot proceed to transplant as a result of a broken chain. Although some crossmatch failures are unavoidable, most can be prevented by the HLA laboratory playing a proactive role in donor selection.
The NKR has developed a number of tools to preview, review and perform exploratory crossmatches on potential donors for hard-to-match patients. Using these tools will improve your patients’ chances for transplant and will reduce virtual crossmatch failures.
Good communication and understanding between the laboratory, coordinators, physicians and surgeons is a key to success in paired exchanges. Transplant programs differ with respect to resources and experience. What works at some centers will not work at others.Establish an understanding of your crossmatch results with the transplant team
- Convey the importance of avoiding or at least reporting potential sensitizing events to the transplant team and to the laboratory. Patients should notify the team prior to being transfused, having surgery, etc. Retest patients whose antibody profiles may have changed
- Review patients with special requirements for compatibility (children, patients unable or unwilling to accept a donor with potential incompatibilities)
- Establish crossmatch thresholds with your transplant team. Borderline positive or negative results may change with retesting. Flow cytometry results are semi-quantitative. Rather than a dichotomous positive or negative, flow values provide an indication of increasing risk
- Anticipate confounding crossmatch results
- Screen for IgM or autoantibodies
- Treat patient sera with DTT or EDTA to reduce prozone effects in solid-phase tests
- Test sera at dilution to identify weak antibodies or antibodies at saturation
- Don’t enroll patients with non-HLA antibodies that will preclude a transplant
- List more low level avoids for easy-to-match pairs (pair match power>30)*
- List more low-level avoids for patients who will not tolerate aggressive immunosuppression, plasmapheresis or who otherwise require a completely DSA-free transplant
- Review donors with one avoid HLA antigen
- Remove one or more weak avoids to see potential donors
- Determine whether desensitization is feasible for specific incompatibilities
- Review ABOi donors for 100% CPRA patients (ABOi is often less difficult than desensitization for HLA)
- Report NMDP codes for donor antigens you type at intermediate resolution.
- Contact the donor center laboratory to ask for donor typing details in specific cases.
- Use tools like NMDP’s website (http://www.haplostats.org/haplostats?execution=e1s1) to predict allele types based on high resolution haplotype frequencies
- Use tools like the epitope registry (http://www.epregistry.com.br)to evaluate allele reactivities in the context of shared potential epitopes
- Weak DSA
- Multiple low-level DSAs
- Cw, DQ or DP DSAs with uncertain crossmatch potential
- Allele-specific antibodies not likely to react with a selected donor
- The exploratory cross match should be requested as soon as the potential donor becomes available via preselect
Cryopreservation of donor lymphocytes obviates the need to recall donors when an exploratory crossmatch is requested for the donor. This makes life easier for coordinators and the donors, but it also speeds the exploratory crossmatch process and facilitates transplantation of patients in the NKR.
- If your laboratory routinely freezes and stores lymphocytes, please freeze cells on each NKR donor and indicate that frozen cells are available on the donor form. Guidelines for uniform preparation, storing and shipping are available on the NKR website here
- If you have the resources to freeze and store cells, but do not currently, guidelines for uniform preparation, freezing and thawing are available on the NKR website here
- If you cannot freeze cells, NKR has contracted with a commercial laboratory, which will process, freeze, store and ship cells for your donors. The cost for this service is charged to the donor’s recipient
- Whether you freeze cells or utilize the commercial laboratory services, accept frozen cells for exploratory crossmatches
NKR HolidaysThe NKR will not schedule surgeries on the following holidays:
- New Years
- Memorial day
- Independence Day
- Labor day