Medical Board Policies

  1. Match Offer Selection – The National Kidney Registry (NKR) shall select match offers based on the following scientific and objective criteria:
    1. Voucher holder Patients shall be prioritized over paired recipient Patients
    2. When adequate time is available, match offers shall be selected to facilitate the most possible transplants except when hard to match Patients can be matched.
    3. When adequate time is not available, match offers shall be selected to maximize the probability that the swap will be successful.
    4. When multiple potential match offers yield similar numbers of transplants, in addition to the considerations outlined above, the following priorities shall apply:
      1. Priority #1: Pediatrics (18 years old or younger).
      2. Priority #2: Centers with the highest Center Liquidity Contribution (CLC) scores.
      3. Priority #3: Patients with the longest NKR wait times (measured in Days Exportable).
    5. Voucher holder Patients shall be prioritized over paired recipient Patients utilizing the following priorities:
      1. Priority #1: Any former NKR donor in need of a kidney transplant.
      2. Priority #2: Swap Savers or Favorable blood type combo pairs.
      3. Priority #3: Center has CLC score >0, or Neutral blood type combo pair, or NKR cPRA > 97, or pediatrics.
      4. Priority #4: Unfavorable blood type combo pairs at centers with a CLC score < 0.
      5. Priority #5: Special cases as defined below:
        1. Recipients who receive a kidney transplant in NKR swaps who experience graft failure within 90 days of the transplant subject to the conditions below:
          1. Paired or Voucher Recipients whose center reports the issue in the NKR system and provides pictures of the kidney within 8 hours of kidney receipt, will be provided a replacement kidney, if the Surgical Committee following review of the data and circumstances, clearly and confidently determines the graft failure was a result of an impaired kidney that was delivered to the recipient center.
          2. Paired or Voucher Recipients whose center reports the issue in the NKR system after 8 hours but within 90 days of kidney receipt, may be provided a replacement kidney if the recipient surgeon presents the case and the Surgical Committee determines that the graft failure was clearly and confidently a result of an impaired kidney that was delivered to the recipient center.
        2. To ‘O’ blood type Recipients at Partner Centers, whose transplant was facilitated through an NKR swap, and experienced primary non-function subject to review and approval of the Surgical Committee.
          1. Each Partner Center is eligible for one ‘O’ chain end kidney per year.
    6. When a Voucher holder cannot be matched at the end of a chain, the following priorities shall apply:
      1. Priority #1: MCs with a decline ratio (DR) < 100% and a Net Chains Started (NCS) score > 0.
      2. Priority #2: PCs with a DR < 100% and a Chain End Target Score > 0.
        1. The Chain End Target Score calculation is ((4.0 x chains started with ‘O’ family voucher donors in the past 2 years) + (2.0 x chains started with ‘Non-O’ family voucher donors in the past 2 years) + (center’s current NCS score)). Example below:
          Criteria Multiplier Example
          Family Voucher Chains over last 24 months (n) (n)*Multiplier
          – O blood type 4 3 12
          – A, B, or AB blood type 2 4 8
          Net Chains Started 1 -4 -4
          Example Target: 16
    7. The NCS score is defined as the number of chains a center has started less the number of chain end kidneys the center has received.
      1. Voucher donors & voucher holders are excluded from the NCS calculation.
      2. In all cases, a center that receives a kidney will receive a -1 NCS assignment, even if the kidney does not function.
      3. The Surgical Committee has the option to transfer the -1 NCS assignment from the recipient center that utilized the kidney to the donor center, if the recipient surgeon can demonstrate to the Surgical Committee that the graft failure was clearly and confidently a result of an impaired kidney delivered to the recipient center.
  2. Photographing Kidneys – Pictures of all shipped kidneys shall be sent to the recipient surgeon after a phone call or text to the recipient surgeon, both within 1 hour of the completion of the surgery. Pictures shall be taken on the back bench after flushing and shall include:
    1. Allograft parenchyma (demonstrating kidney is well-flushed ‘blanched’)
    2. Any abnormalities (such as cysts, lesions, capsular tears, surgical injuries, etc.)
    3. Renal hilum (highlighting vessel length, multiple vessels and/or ureters). If the kidney is declined after delivery to the recipient center, the recipient center must send pictures of the kidney to the NKR within 2 hours of receipt of the kidney.
  3. 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:
    1. First attempt to cancel or reschedule the swap.
    2. If any of the donor surgeries cannot be aborted, then the NKR Member Centers shall proceed with the swap and the NKR shall work to end a chain to the patient in the failed swap that did not receive a kidney.
    3. 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.
    4. If the patient that did not get a kidney is hard to match (e.g. NKR cPRA > 99%), 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.
    5. In the calculation of “net chains started”, the donor center is accountable for the chain break.
    6. The donor center shall cover all costs related to the donor surgery and donor care.
    7. If the real-time swap failure was caused by the recipient center’s decline of the kidney after the start of the donor surgery, the kidney will remain at the donor center or will be shipped back to the donor center; for transplant into a wait-listed patient, voucher holder or a paired recipient patient.
      1. If the kidney does not remain at the donor center, the NKR will cover the kidney shipping cost.
      2. If a charter flight is requested to expedite the transport of the kidney back to the donor center, the donor center will pay for the charter flight.
      3. The donor and recipient surgeons may be required to review the case with the Surgical Committee.
  4. Voucher Program: The Voucher Program is a paired exchange separated in time.
    1. General
      1. A Voucher donor that starts a chain does not increase a Member Center’s Net Chains Started score.
      2. A Voucher holder that receives a kidney does not decrease a Member Center’s Net Chains Started score.
      3. There is no guarantee that a Voucher holder can be matched or transplanted.
      4. The Voucher donor and Voucher Holder can be at different Voucher participating centers.
    2. Voucher Types
      1. Standard: May identify one patient as an intended recipient for a Voucher who is in imminent need (within 12 months) of a transplant.
      2. Family: May identify up to five family members for Vouchers, none of whom are in imminent need of a transplant. Only one Voucher can be redeemed per Family Voucher kidney donation.
      3. Swap Saver: A donor proceeds with donation to keep the rest of a chain intact even though their paired recipient patient has been removed from the chain due to a swap failure. The paired recipient patient is provided a voucher for their paired donor’s donation.
      4. Real-time Swap Failure: Occurs when a swap fails after one or more of the donor surgeries has begun. When a swap fails in real time the stranded patient is provided a voucher.
    3. Voucher Activation: Centers may activate a Voucher Holder for matching once all of the following requirements are met:
      1. All Voucher consent forms (both donor and Voucher Holder) have been uploaded to the NKR website.
      2. The Voucher donor has donated.
    4. Fast Track Voucher Activation: Centers may fast track Standard Voucher activation under the following conditions:
      1. The Center is a Partner Center in Good Standing.
      2. The donor and patient are a compatible pair.
      3. All Voucher consent forms (both donor and Voucher Holder) are be completed and uploaded to the NKR.
      4. The Standard Voucher donor has completed the workup and is fully cleared for donation.
      5. The Standard Voucher compatible donor activated for matching with a surgery date range of 21 days and ending in 42 days.
    5. Member Center Suspension – The NKR reserves the right to suspend Member Center participation 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 provided and all issues that caused the suspension have been rectified.
    6. COVID Donor Testing – Member Centers shall screen all NKR donors according to the following process:
      1. Only asymptomatic donors with low risk of COVID exposure may proceed with kidney donation.
        1. Screen donors utilizing donor center and CDC Guidelines.
      2. All donors must complete a COVID PCR swab test 1-4 days prior to surgery. Examples below:
        Day of Surgery COVID PCR Test Performed Days Prior to Surgery
        Tuesday Friday 4
        Wednesday Saturday 4
        Thursday Sunday 4
        Friday Monday 4
        1. If the donor tests positive, the donor surgery will be delayed or cancelled.
        2. PCR test results must be uploaded to the NKR systems by 15:00 ET the day prior to surgery to provide visibility of the test results to the recipient center prior to the kickoff call.