KAPP Implements Recommendations from NKF Kidney Discards Conference

New York, NY—July 17, 2019—Today the Organ Procurement and Transplantation Network (OPTN) announced the launch of the Kidney Accelerated Placement Project (KAPP) to assess whether accelerating the placement of extremely hard-to-place kidneys via the Organ Center can increase their utilization. This significant step is derived from recommendations outlined in a report by the National Kidney Foundation and published in the journal Clinical Transplantation, the Journal of Clinical and Translational Research, theReport of National Kidney Foundation Consensus Conference to Decrease Kidney Discards” in October, 2018. The report focused on decreasing the number of kidneys discarded and provided the first systematic nationwide approach to reducing kidney discards.
“When reviewing both the President’s Executive Order on Advancing American Kidney Health and the new OPTN’s Kidney Accelerated Placement Project (KAPP), it is important to appreciate the role that the NKF and the Foundation’s sponsored Kidney Discard Conference had in both influence and structure,” said Matthew Cooper, MD, Co-Chair of the NKF Consensus Conference to Decrease Kidney Discards, and Director of Kidney and Pancreas Transplant at Medstar Georgetown Transplant Institute and Professor of Surgery at Georgetown University School of Medicine. “One of the primary recommendations of that Discard Conference was the creation of an expedited placement pathway to directly offer organs at risk of discard to a small subset of centers that opt in to accepting these organs.  Centers must sustain high rates of acceptance to continue to receive these offers.  The OPTN’s KAPP project is the realization of that NKF recommendation.”
“NKF has been championing the kidney discards issue for several years and as a kidney patient who received a deceased donor transplant, I am grateful to the Administration for their focus on making more kidneys available for transplant so that more patients will receive the same second chance that I did,” said Kevin Longino, CEO of NKF.
“We are very pleased that OPTN has launched the Kidney Accelerated Placement Project focusing on two of our fourteen recommendations to reduce kidney discards nationwide; and that UNOS recognizes the need to change the allocation system to expedite placement of organs that would otherwise be discarded,” said Stephen Pastan MD, Co-Chair of the NKF Consensus Conference to Decrease Kidney Discards and Professor of Medicine, Renal Division, Department of Medicine, Emory University School of Medicine.
“It is the Foundation’s hope and expectation that this change in allocation will increase the number of viable kidneys that proceed to transplant as well as to encourage transplant programs to take a critical look at their acceptance patterns to potentially increase organ acceptance and decrease intra-center acceptance variability between physicians.  Importantly, NKF encourages the patient voice to become an integral part in the decision-making for all organ allocation practices moving forward, added Cooper.”    
The 14 specific recommendations in the published in the Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards are:
  • Strengthen local Organ Procurement Organization (OPO) and transplant center cooperative Quality Assurance and Performance Improvement (QAPI) efforts to reduce discard to identify the root causes of failure to place kidneys locally and implement solutions to increase allocation.
  • Improve communication between OPO and Accepting Transplant Surgeon at time of organ placement to improve information used to make acceptance decisions.
  • Routinely send prospective crossmatch to at least three transplant centers to speed up time to acceptance in case initial centers do not accept the kidney.
  • Grant “local backup” to centers receiving exported kidneys to ensure shipped organs can be used at first destination.
  • Identify “local backup” in local DSA for shared allocation of high Calculated Panel Reactive Antibodies (CPRA) or high KDPI kidneys to decrease the need for organ export.
  • Expand use of virtual crossmatching to decrease the time to decision on acceptance by avoiding the need for testing of shipped specimen prior to transplant.
  • Involve the nephrologist working cooperatively with the surgeon in decisions regarding organ acceptance to share responsibility and utilize the medical knowledge of the nephrologist in acceptance decisions that consider downstream risks of acceptance versus refusal of a given kidney for each specific patient.
  • Improve practitioner and patient education on acceptance of higher risk for discard kidneys to prevent delays in acceptance and speed up decisions regarding kidney acceptance. 
  • Disseminate best practices from OPOs and transplant centers that routinely accept high risk organs to increase the number of centers which utilize high risk organs.
  • Create expedited placement pathways to directly offer organs at risk of discard to small subset of centers that opt-in to accepting these organs.  Center must sustain high rates of acceptance to receive offers.
  • Identify organs that become a risk for discard during standard allocation and allocate them to patients in rescue centers that utilized high-risk organs when standard placement has been unsuccessful to place limit on time that the kidney is in standard allocation pathway to ensure it is transplanted.
  • Standardize technical aspects of obtaining and interpreting renal (deceased donor) biopsies to utilize renal pathologists to improve decision making based on biopsy.
  • Standardize provision of gross photos of procured kidneys and post on DonorNet to better inform the surgeon on condition of procured organ.
  • Develop risk adjusted payment system to cover increased costs of high-risk kidneys to remove disincentive to accept the organ which may result in an increased risk of post-transplant morbidity with associated cost.
About Kidney Discards
There are many reasons why kidneys are discarded including poor organ quality, abnormal biopsy findings, prolonged cold ischemic time, anatomy, punitive regulatory and payer sanctions due to poor clinical outcomes, and the increased costs associated with the use of higher kidney donor profile index (KDPI) grafts, the report points out, yet experts believe and data supports that many of these kidneys can be used for transplant. Kidney discard rates also vary upon geography leading experts to believe that the variation may be based on a subjective view of organ viability by an individual transplant team.  Every year kidneys that could be used for transplant are discarded.  In 2016, more than 3,600 were deemed unfit for transplant and thrown away.  But a panel of transplant experts convened by NKF agree that as many as 50% of those kidneys could be transplanted to prolong the lives of Americans otherwise treated with dialysis. The recommendations chronicled in the published report emerged from NKF’s Consensus Conference to Reduce Kidney Discards, held in May 2017 with 75 multidisciplinary experts in the transplant field including kidney patients and families.
About Kidney Disease
In the United States, 37 million adults are estimated to have chronic kidney disease (CKD) – and most aren’t aware of it.  1 in 3 American adults is at risk for CKD.  Risk factors for kidney disease include diabetes, high blood pressure, heart disease, obesity, a family history of kidney failure, and being age 60 or older. People of African American, Hispanic, Native-American, Asian or Pacific Islander descent are at increased risk for developing the disease. African Americans are about 3 times more likely than Whites to develop end-stage kidney disease (ESKD or kidney failure). Compared to non-Hispanics, Hispanics are almost 1.3 times more likely to receive a diagnosis of kidney failure.
More than than 726,000 Americans have irreversible kidney failure, or end-stage renal disease (ESRD), and need dialysis or a kidney transplant to survive. More than 500,000 of these patients receive dialysis at least three times per week to replace kidney function. Nearly 100,000 Americans are on the waitlist for a kidney transplant right now.  Depending on where a patient lives, the average wait time for a kidney transplant can be upwards of three to seven years. Living organ donation not only saves lives, it saves money. Each year, Medicare spends approximately $89,000 per dialysis patient and less than half, $35,000, for a transplant patient.
The National Kidney Foundation (NKF) is the largest, most comprehensive and longstanding organization dedicated to the awareness, prevention and treatment of kidney disease. For more information about NKF visit www.kidney.org.