Member Center Guidelines

The following guidelines are for all NKR Member Centers.

  1. 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 Amsterdam 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. As of 11/1/17 the NKR began purchasing donation insurance for all donors who donate a kidney through NKR.
    1. Member Centers are encouraged to use the NKR Donor Chart format when uploading a donor chart.
    2. Basic Evaluation:
      1. Complete history and physical.
      2. Height, weight, BMI.
      3. BP at two different settings on different days.
      4. General laboratory to assess:
        1. hematologic status.
        2. coagulation.
        3. electrolytes.
        4. fasting lipids and glucose.
        5. liver status.
      5. CXR.
      6. ECG.
      7. Age appropriate evaluation for cancer.
      8. Donor work-ups must be repeated in their entirety, every 12 months, except for CT angio, unless the first CT angio was abnormal.
    3. Kidney Evaluation:
      1. Urinalysis with microscopy.
      2. Urine culture if indicated.
      3. 24-hour urine or Cystatin-C for albumin excretion and creatinine clearance.
      4. Anatomic Testing for anatomy definition.
      5. If a donor GFR reading is below 85, the center will perform a nuclear medical GFR test to confirm the donor’s GFR.
      6. The minimum acceptable GFR for donors age 60 and under is 80. The minimum acceptable GFR for donors over age 60 is 75.
      7. If there is > 10% difference in donor kidney size (between the two kidneys) then the smaller kidney will be offered for donation.
      8. 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/Gm.
    4. Tuberculosis screening:
      1. Chest X-Ray (CXR).
      2. Criteria for high risk donors: (based on history and physical)
        1. Birth or residence in a TB endemic country.
        2. Close contacts of individuals with TB (Household or family members).
        3. Donors who work or have resided in homeless shelters, correctional facilities, nursing homes, or hospitals.
        4. History of IV drug use.
        5. Evidence of granulomas or healed TB on CXR.
      3. For donors meeting the criteria for high risk we recommend Interferon-gamma release assays (IGRAs) or tuberculin skin test (TST).
      4. Recipient center may choose to have additional testing performed at time of match offer acceptance.
    5. Infectious disease screening:
      1. CMV.
      2. EBV.
      3. HIV 1,2.
      4. HBsAg, HBcAB, HBsAB.
      5. HCV.
      6. RPR.
      7. Depending upon time of year and location associated risk:
        1. Strongyloides.
        2. Trypanosoma cruzi.
        3. West Nile Virus.
        4. Toxoplasmosis.
    6. Suggested evaluation for donors at risk for metabolic syndrome or diabetes:
      1. Uric acid.
      2. HbA1C.
      3. Glucose tolerance testing.
    7. Stone Disease:
      1. 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:
        1. No hypercalcuria, hyperuricemia, or metabolic acidosis.
        2. No cystinuria, or hyperoxaluria.
        3. No urinary tract infection.
      2. An asymptomatic potential donor with a current single stone may be suitable if:
        1. The donor meets the criteria shown previously for single stone formers.
        2. The current stone is less than 1.5 cm in size, or potentially removable during the transplant.
      3. Stone formers who should not donate are those with:
        1. Nephrocalcinosis on x ray or bilateral stone disease.
        2. Stone types with high recurrence rates, and are difficult to prevent.
  2. 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:
    1. 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.
    2. 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.
    3. 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.
    4. Charges are routed to Organ Acquisition for up to 90 days or up to 6 months if potentially related to complications.
    5. After these time periods, facility charges may not be allowable on the Medicare Cost Report.
    6. In all of these situations, the donor is not responsible for co-insurance or deductible.
  3. 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:
    1. 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.
      1. If an NDD donates to someone on the center’s wait list, the scheduling of the surgery may be easier for the NDD.
      2. If an NDD starts a chain of transplants, they will generally help more people get transplants.
      3. It often requires a long wait time for “A” and “AB” blood type NDD’s to start a chain of transplants.
    2. 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.
    3. Centers should ensure that the NDD can get appropriate time off from work.
    4. Centers should determine the NDD’s availability for surgery and accurately enter it into the NKR system.
    5. 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.
    6. The Center should inform the NDD that there may be financial support available to assist them in the donation process if they qualify.
  4. 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 follows:
    1. Bridge donors should be prepared to donate between one week and three months of their paired recipient’s surgery with no significant schedule limitations.
    2. Bridge donors must have no significant medical risks that could prohibit them from donating.
    3. The donor center must be confident that the bridge donor will follow through with donation.
    4. New centers may want to complete at least three exchange transplants prior to identifying donors as bridge donor candidates.
    5. Member center guidelines for educating and evaluating donors to qualify a bridge donor candidate should include:
      1. Discussions regarding the possibility of being a bridge donor should begin at initial donor evaluation and continue throughout the process.
      2. 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.
      3. When asking a donor to bridge, an in-person discussion should occur and include the donor’s support person.
      4. Member centers must maintain frequent contact with bridge donors.
      5. 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.
      6. 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.
      7. Member centers should re-educate donors and reconfirm their availability prior to accepting the donor for a bridge position in a swap.
  5. Voucher Donors
    1. Standard Voucher Donors are encouraged to give a minimum 30 day window for their donation range.
    2. The voucher donor must complete and return the consent forms to apply for voucher participation.
    3. A voucher donor may identify one intended recipient patient for a Standard Voucher or up to five intended recipient patients in their immediate family for Family Vouchers.
    4. Up to five voucher donors can identify the same intended recipient.