Medical Board Policies

• Match Offer Selection
• Photographing Kidneys
• Managing Real-Time Swap Failures
• Voucher Program
• Member Center Suspension

Match Offer Selection

The National Kidney Registry (NKR) shall select match offers based on the following scientific and objective criteria:

1. Voucher holder patientsA person in need of a kidney transplant. shall be prioritized over paired recipient patientsA person in need of a kidney transplant. .
2. When adequate time is available, match offers shall be selected to facilitate the maximum number of possible transplants except when hard-to-match patientsA person in need of a kidney transplant. 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. O blood type patientsA person in need of a kidney transplant. with incompatible donors will not be matched with donors who are more than 10 years younger than the patient unless an eplet mismatch preference is recorded or the patient has a cPRA > 99.0%.
5. 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: PatientsA person in need of a kidney transplant. with NKR Voucher wait times greater than 6 months or paired patientsA person in need of a kidney transplant. with wait times greater than 12 months.
   3. Priority #3: Low eplet mismatches.
   4. Priority #4: PatientsA person in need of a kidney transplant. at centers with a Compatible Pair Ratio (CPR) ≥ 40% over the last 12 months.
6. Voucher holder patientsA person in need of a kidney transplant. shall be prioritized over paired recipient patientsA person in need of a kidney transplant. utilizing the following priorities:
   1. Priority #1: Any former NKR donor in need of a kidney transplant.
   2. Priority #2: Swap saversA voucher type where the paired donor proceeds with donation to keep the rest of a swap on schedule, but their paired recipient does not receive a transplant in the swap. or voucher holders waiting > 24 months since voucher donor donated or favorablePaired donor blood type of 'O' AND patient blood type of 'A', 'B' or 'AB' blood type combo pairs.
   3. Priority #3: Center has CPR ≥ 40%, or neutralPair that does not meet the definition of a 'Favorable' or 'Unfavorable' blood type combination. blood type combo pair, or NKR cPRACalculated Panel Reactive Antibodies based on the historical NKR donor pool and patient avoids using a brute force calculation method. > 97, or pediatrics.
   4. Priority #4: UnfavorablePaired donor blood type of 'A', 'B' or 'AB' AND patient blood type of 'O' blood type combo pairs at centers with a CPR < 40%.
   5. Priority #5: Special cases as defined below:
      1. RecipientsA patient who has received a kidney transplant. 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 recipientsA patient who has received a kidney transplant. 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 recipientsA patient who has received a kidney transplant. 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 recipientsA patient who has received a kidney transplant. 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.
7. 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) < 30% and a net chains started (NCS) score > 0.
   2. Priority #2: PCs with a DR < 30% and a Targeted Chain End Score > 0.
      1. The Targeted Chain End Score calculation is based on a center’s composite score (CS) as compared to all Partner Centers’ composite scores. The CS is the sum of voucher chain starters who donated in the past 12 months plus the compatible pairs transplanted in the past 12 months. If the PC accepts kidneys with any anatomy, and has a DR equal to zero, the composite score receives a 20% bonus. Then the sum of all composite scores is used to determine that centers share of the composite score. This percentage is used to determine that center’s share of the ‘Float with Buffer.’ We then add the Net Chain Started Deficit to determine the Targeted Chain End Score. Example below:
         

         Criteria	Value
         Standard Vouchers	22
         Family Vouchers	18
         Compatible Pairs	17
         DR = 0% and Any Anatomy	0
         Total Composite Score	57
         Total of ALL Composite Scores	592
         Share of Total Composite Scores	9.63%
         Float with Buffer	654
         Share of Float	63
         Net Chain Started Deficit	-48
         Targeted Chain End Score	15

8. The NCS score is defined as the number of NDD chains a center has started less the number of chain end kidneys the center has received excluding voucher holder chain ends.
   1. The Net Chain Started Deficit adds in the total unredeemed family voucher chain starts to the NCS score.
   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.

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.

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, the NKR shall:

1. First attempt to cancel or reschedule the swap.
2. If any of the donor surgeries cannot be aborted, 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 cPRACalculated Panel Reactive Antibodies based on the historical NKR donor pool and patient avoids using a brute force calculation method. > 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 waitlisted patient, voucher holder or 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.

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 (NCS) score.
   2. A voucher holder that receives a kidney does not decrease a Member Center’s net chains started (NCS) 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 Voucher: May identify one patient as an intended recipient for a voucher who is in imminent need (within 12 months) of a transplant. Standard voucher donors may also name up to five family members as back-up voucher holders should the initial voucher holder receive a deceased donor transplant.
   2. Family Voucher: 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: This allows a patient to be activated for matching at the same time as the donor. In these cases, the patient could receive a match offer before the donor is matched. Centers may fast-track standard voucher activation under the following conditions:
   1. The transplant center is a Partner Center in good standing.
   2. All voucher consent forms (both donor and voucher holder) must be completed and uploaded to the NKR.
   3. The standard voucher donor has completed the workup and is fully cleared for donation.
   4. The standard voucher donor is activated for matching with a surgery date range of 21-42 days.

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.