EVIDENCE BASED INSIGHT
Increasing Access to Transplantation: Lessons from the United States
Against this backdrop, data from the United States Renal Data System show that kidney transplantation has continued to increase. There were approximately 15,000 deceased donor transplants in 2017, a new high in this century. The number of living donor transplants remained slightly below 6,000, although there have been steady increases in both unrelated directed altruistic donation and paired exchange (programs allowing incompatible recipients to receive a better matched kidney) in recent years. The increase in overdose-related deaths in the general population may be contributing to this increase, as motor vehicle deaths have continued to decline.
A variety of initiatives have been launched at Fresenius Kidney Care (FKC) and Fresenius Medical Care North America (FMCNA) to improve patient access to transplantation. Within the FKC electronic health record (eCube Clinicals), the transplantation workflow and documentation of referral to a transplant center have been modified to include more clinical detail and better visibility to reasons for non-referral. Since patient refusal is a major barrier to transplant, educational counseling delivered by social workers and other members of the intradisciplinary care team is expanding emphasis on transplantation as a modality option. Recognizing “Percentage of Prevalent Patients Waitlisted (PPPW)” as a new metric within the Medicare Quality Improvement Program, the FKC Clinical Quality Score (the internal quality reporting program for FKC clinics) will display “Transplant Waitlist” in 2020, showing the percent of eligible patients < 75 years of age on the transplant waitlist as gathered from the Transplant Assessment in eCube Clinicals (Figure 2).2
While kidney donations from living relatives are widely known and specifically sought when patients undergo evaluation, unrelated or “altruistic” donation is less publicized and occurs infrequently. The recently established Fresenius Medical Care Foundation has recognized an opportunity to increase altruistic donation by partnering with Donate Life America (DLA) to create a national registry of individuals willing to donate a kidney.
Further, with Fresenius Medical Care Foundation support, DLA will distribute saliva testing kits to rapidly determine suitability and match donor tissue type with potential kidney recipients. Additionally, FMCNA has provided funding to the National Kidney Foundation’s “Big Ask, Big Give” initiative to help educate patients and families about living donation and suitability as a donor.
Nephrologist leadership and commitment are essential to increase the kidney transplantation rate (Figure 3).3 FMCNA physician education on transplantation is provided through the Medical Office Newsroom, Medical Office Live events, and regular Medical Office communications. New payment models identified in the executive order emphasize the key role of nephrologists in CKD care and appropriate planning for ESKD choices. InterWell, an innovative partnership between FMCNA and nephrologists, is a population management company focused on improving CKD care, increasing home dialysis utilization, and promoting kidney transplantation.
Outside of Fresenius Medical Care, significant improvements in the US transplant system are necessary. Under new proposed regulations, OPOs will be required to report deceased donor transplant donation rates and transplantation rates. The quality measure for the transplant programs needs to evolve to eliminate both the excessive denial of transplants to candidates with complicated medical conditions and the refusal to transplant “less than perfect” donated kidneys.
It is clear that progress requires a multifaceted approach to change. Leadership from nephrologists, systemic improvements including new payment models, national campaigns promoting donation, and more in-depth conversations between patients and interdisciplinary care teams are just some of the factors that can help remove excessive barriers to renal replacement therapy.
PARTNERSHIP'S INITIATIVES WILL ENCOURAGE LIVING DONATIONS
The Fresenius Medical Care Foundation has made an investment in two initiatives being launched by Donate Life America (DLA), a nonprofit organization focused on increasing organ transplantation. One initiative is a national, universal living donor kidney registry; the other is the first-ever at-home living donor testing kit. Both will encourage living donations by alleviating wait times for individuals on the kidney transplant waiting list and increasing patient access to living donor transplants.
At-Home Living Donor Testing Kits: Using saliva sample technology, a faster, consumer-friendly screening option has been created to identify and register potential living donors for kidney transplant. The streamlined process helps retain living donor interest by converting testing results to a potential match as quickly and safely as possible.
The National Donate Life Living Donor Registry: This first-of-its kind universal registry will allow the public to register their interest in becoming a living donor, reducing the barriers that currently exist with no clear pathway to express interest. This platform captures preliminary matching results from the at-home testing kits and—in partnership with the United Network for Organ Sharing and transplant programs across the country—allows potential living donors and recipients to find matches nationwide. This new living donor registry is part of the existing secured and trusted National Donate Life Registry, which houses deceased organ, eye, and tissue donor registrations.
Meet The Experts
- US Organ Procurement and Transplantation Network and Scientific Registry of Transplant Recipients. OPTN/SRTR 2017 annual data report: kidney. https://srtr.transplant.hrsa.gov/annual_reports/2017/Kidney.aspx.
- Guide to the dialysis facility reports for fiscal year 2019. Table 6 for calendar year 2017. University of Michigan Kidney Epidemiology and Cost Center, July 2018. https:// dialysisdata.org/sites/default/files/content/Methodology/DFRGuide.pdf.
- Guide to the dialysis facility reports for fiscal year 2019. Table 5 data. University of Michigan Kidney Epidemiology and Cost Center, July 2018. https://dialysisdata.org/ sites/default/files/content/Methodology/DFRGuide.pdf.
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