A Roadmap for Innovation to Advance Transplant Access and Outcomes: A Position Statement From the National Kidney Foundation

Over the past 65 years, kidney transplantation has evolved into optimal treatment for patients with failure, dramatically reducing suffering through improved survival and quality of life. However, access to transplant is still limited by organ supply, opportunities are inequitably distributed, lifelong remains elusive. To address these persistent needs, National Kidney Foundation convened an expert panel define agenda future research. The key priorities identified center on needs develop evaluate strategies expand living donation, improve waitlist management readiness, maximize use available deceased donor organs, extend allograft longevity. Strategies targeting critical goal decreasing discard that warrant research investment include educating clinicians about potential benefits accepting nonstandard novel assessment technologies real-time decision support, approaches preserve resuscitate allografts before implantation. development personalized reduce burden immunosuppression support “one life” was also as a vital priority. noted specific improving graft children failure. This ambitious will focus promote greater equity efficiency in transplantation, help sustain long-term gift life more need. As this article reflects official position (NKF) because it reviewed approved NKF, not peer AJKD. prepared work group comprising authors chaired Dr Krista Lentine. It NKF Scientific Advisory Board Executive Committee. transplantation—and especially living-donor (LDKT)—offers failure best chance life, at lowest costs health care system.1Axelrod D.A. Schnitzler M.A. Xiao H. et al.An economic contemporary practice.Am J Transplant. 2018; 18: 1168-1176Crossref PubMed Scopus (102) Google Scholar,2Alhamad T. Axelrod D. Lentine K.L. epidemiology, outcomes, transplantation.in: Himmelfarb J. Ikizler T.A. Chronic Disease, Dialysis, Transplantation: A Companion Brenner Rector’s Kidney. 4th ed. Elsevier, 2019Crossref (2) Scholar There have been many positive trends recent including progressive rise rates improvements short- longer-term survival.3Hart A. Smith J.M. al.OPTN/SRTR 2019 Annual Data Report: kidney.Am 2021; 21: 21-137Crossref (58) field continues face important challenges. vast majority than 700,000 persons United States opportunity receive due limitations supply. Those who often ultimately return dialysis resulting from chronic nephropathy, recurrence native disease, medication nonadherence, or other causes.2Alhamad Scholar,4Alhamad Lubetzky M. al.Kidney recipients transition (KRAFT): survey practices providers.Am (Published online February 8, 2021. doi:10.1111/ajt.16523)Crossref (4) Efforts supply increased kidneys older donors some extent, yet potentially transplantable organs continue go unused. Decisions recovered generally attributed quality, but are, fact, multifactorial, reflecting opinions benefit, cost, program regulatory risk, logistical complexity, all which supported evidence-based assessments. population need increasingly complex diverse, higher prevalence patients, well individuals comorbidities (eg, obesity, diabetes mellitus, cardiac disease) non-White race ethnicity (Fig 1).2Alhamad Furthermore, LDKT adults stagnated while racial disparities persist worsen.5Purnell T.S. Luo X. Cooper L.A. al.Association live 1995 2014.JAMA. 319: 49-61Crossref (104) increase received unprecedented federal government July Advancing American Health executive order, articulated goals increasing initiation replacement therapy substantially number 2030.6Lentine Mannon R.B. (AAKH) Order: promise caveats expanding transplantation.Kidney360. 2020; 1: 557-560Crossref These efforts were initially hampered global coronavirus disease (COVID-19) pandemic, although both subsequently prepandemic levels.7Pereira M.R. Mohan S. Cohen D.J. al.COVID-19 solid recipients: Initial report US epicenter.Am 20: 1800-1808Crossref (418) Scholar,8Lentine Vest L.S. al.Survey donation COVID-19 era.Kidney Int Rep. 5: 1894-1905Abstract Full Text PDF (28) Scholar9Lentine Josephson Practicing uncertainty: during pandemic.Am Dis. 77: 777-785Abstract (10) assess knowledge gaps amenable aimed advancing practice outcomes panel. charged developing facilitate can recipients, reduce/eliminate ethnic outcomes. Participants included nephrologists, surgeons, procurement organization (OPO) leaders, leadership, interested parties. Consensus-building conducted email, conference calls, in-person roundtable meeting December 13, 2019, New York City. Through facilitated discussions, developed 7 innovations. occurred shortly recommendations updated context latest challenges facing field. Living be related, unrelated, nondirected, participants exchange (kidney paired [KPD]) programs. Benefits over faster superior patient cost In States, declined 6,000 2004 approximately 5,500 per year 20173Hart Scholar; 2018-2019 showed promising trend nearly 6,900 LDKT, growth stalled 2020 temporary disruption activity start pandemic.9Lentine Barriers candidate’s ability identify willing appropriate donor, concerns follow-up, barriers out-of-pocket expenses lost wages.10Lentine Mandelbrot Moving intuition data: building evidence transplantation.Clin Am Soc Nephrol. 2017; 12: 1383-1385Crossref (9) Development KPD programs biologically incompatible advance LDKT.11Garg N. Gill Compatibility, transplants.in: Concepcion B.P. Lerma E.V. Donation: Best Practices Evaluation, Care Follow-up. Springer International, 2021: 233-251Crossref Using algorithms among 2 donor–recipient pairs, create compatible combinations blood donor-specific alloreactivity incompatibilities. Nondirected (ie, do recipient) provide unique pool chains exchanges.12Melcher M.L. Leeser D.B. Gritsch H.A. al.Chain transplantation: initial experience large multicenter program.Am 2012; 2429-2436Crossref (47) fastest growing modality currently comprises 16% 2).3Hart underused physician acceptance, degree allosensitization. If centers used rate high-performing centers, estimated another 1,000 transplants could performed annually.13Massie A.B. Gentry S.E. Montgomery R.A. Bingaman A.A. Segev D.L. Center-level utilization donation.Am 2013; 13: 1317-1322Crossref (45) Entering pairs suggestion further matches such better balance mass/function exchanged donors, tissue matching reduced eplet mismatches) lower rejection risk.14Gentry Simmerling Expanding participation pairs.Am 2007; 7: 2361-2370Crossref (120) Additional innovations “advanced donation,” wherein gives voucher their intended recipient later time if when needed, designed overcome “chronological incompatibility.”15Veale J.L. Capron A.M. Nassiri al.Vouchers incompatibility” between recipients.Transplantation. 101: 2115-2119Crossref (29) Other educational interventions, public campaigns, evaluation efficiencies, mitigation efforts.16Hunt H.F. Rodrigue J.R. Dew al.Strategies knowledge, communication, review inform education.Curr Transplant 27-44Crossref (15) scoping review, Barnieh al 26 studies reporting LDKT.17Barnieh L. Collister Manns B. al.A donation.Clin 1518-1527Crossref (31) Patient education only strategy empirically assessed randomized clinical trials, (involving home-based candidates members social network) found significant increases evaluations.18Rodrigue Cornell Kaplan Howard R.J. trial approach effects blacks whites.Am 2008; 51: 663-670Abstract (97) Scholar,19Ismail S.Y. Luchtenburg A.E. Timman R. al.Home-based family intervention communication rates: controlled trial.Am 2014; 14: 1862-1869Crossref (55) Despite urgent 6 quasi-experimental 13 observational diverse education, awareness advocacy (training champion), (web-based screening, creation interdisciplinary teams), removal disincentives (leave policies, tax benefits), institution study systematic structured families.20Schweitzer E.J. Yoon Hart al.Increased volunteer formal 1997; 29: 739-745Abstract (68) Further, well-designed trials needed successful interventions populations access. Recently, body quantified estimates risks tool using candidate demographic characteristics estimate (in absence donation) 15-year lifetime risk (https://www.ckdpc.org/tools.html).21Grams M.E. Sang Y. Levey A.S. al.Kidney-failure projection kidney-donor candidate.N Engl Med. 2016; 374: 411-421Crossref (229) required validate precision tools22Grams Garg A.X. Kidney-failure 2094-2095PubMed incorporate emerging factors apolipoprotein L1 [APOL1] genetic marker).23Lentine Apolipoprotein L1: role donors.Curr Opin Nephrol Hypertens. 645-655Crossref Unfortunately, methods effectively communicating information poorly studied. Even though transparent safety primarily directed sustaining trust informing selection practices.24Lentine Kasiske B.L. al.KDIGO Clinical Practice Guideline donors.Transplantation. S1-S109PubMed registries tracking needed.25Kasiske Asrani S.K. al.The Donor Collective: scientific registry donors.Am 17: 3040-3048Crossref (23) Scholar,26Kasiske Ahn Y.S. Conboy al.Outcomes evaluations Collective pilot registry.Transplant Direct. e689Crossref (0) Attention Black, Hispanic, those levels socioeconomic status literacy, priority.27Lentine Addressing call action.Clin 1909-1911Crossref (11) Although removing financial broadly accepted necessary demonstrating impact neutrality date.28Tushla Rudow Milton al.Living-donor donation--recommendations consensus conference.Clin 2015; 10: 1696-1702Crossref (62) burdens particularly vital, pandemic-related recession may challenge beyond end emergency. Technology enable efficient delivery, determine e-learning, telehealth, telephone-based effective education. Further generate standards modifiable process delays.29Habbous Woo Lam N.N. evaluating donation: review.Transplant 4: e394Crossref Scholar,30Habbous Klarenbach al.Evaluating multiple simultaneously cost-effective sequentially.Kidney Int. 98: 1578-1588Abstract Dissemination whether scaled unexpected arise wider implementation. agreed suggestions high-priority should developing, accessing 3)10Lentine to:•Improve outreach identification;•Reduce donation;•Improve predonation processes, particular attention patients;•Optimize follow-up; and•Identify implement transparency, shared decision-making evaluation. Among 95,000 waiting combined kidney/pancreas March 2021, 43% had inactive status.31Organ Procurement Transplantation Network (OPTN). Current U.S. list.https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/#Google Thus, despite being for, presumably of, transplant, appear match run offers. Patients variety reasons current medical illness, psychosocial barriers, preserved function meets listing criteria does therapy). listed twice mortality 32% eventual active.32Grams Massie Schold J.D. Chen Trends implications survival.Am 1012-1018Crossref (35) list minority populations. One national records that, inactive, Black 19% less likely convert active Hispanic 27% White counterparts.33Huang E. Shye Elashoff Mehrnia Bunnapradist Incidence conversion temporarily obese renal candidates.Transplantation. 177-186Crossref (26) disparity directly impacts overall mortality. referral difficult navigate. must complete rigorous testing examinations ensure there no surgical contraindications transplantation. Racial completing documented even after controlling determinants health.34Ng Y.H. Pankratz V.S. Leyva al.Does waitlisting accounting health?.Transplantation. 104: 1445-1455Crossref (16) Time- resource-intensive navigators, individually tailored programs, coaching) proportion successfully waitlisted single-center trials.35Nishio-Lucar A.G. Locke Kumar V. Use navigators transplantation.Curr Transpl 72-80Crossref (1) disseminate inactivation lists. Kataria reported frequent programmatic allowed 18% made active, led delisting 40% center.36Kataria Gowda Lamphron Jalal K. Venuto R.C. Gundroo waitlist.BMC 2019; 174Crossref considered target interventions. For example, mass index exceeding acceptance thresholds referred nutritional possible bariatric surgery.37Lentine Delos Santos Brennan D.C. Tuttle-Newhall J.E. Obesity candidates: how big too transplantation?.Am 36: 575-586Crossref (83) Scholar,38Lentine Pro: Pretransplant weight loss: yes.Nephrol Dial 30: 1798-1803Crossref Bariatric procedures shown achieve durable loss candidates.39Modanlou K.A. Muthyala U. al.Bariatric surgery analysis data system literature review.Transplantation. 2009; 87: 1167-1173Crossref (118) Scholar,40Orandi B.J. Purvis J.W. Cannon R.M. end-stage patients: meta-analysis.Am Surg. 220: 566-579Abstract (6) review/meta-analysis 288 advanced demonstrated 50% sufficient listing.40Orandi disease. Frailty barrier frail half nonfrail counterparts transplant.41Kobashigawa Dadhania Bhorade al.Report Society frailty transplantation.Am 19: 984-994Crossref (91) Scholar, 42Cheng X.S. Koraishy F.M. Myers Tan J.C. Implications peritransplant recipients.Curr 6: 16-25Crossref (20) 43Harhay M.N. Rao M.K. Woodside K.J. overview measurement, considerations.Nephrol 35: 1099-1112Crossref (21) transplants, 20% determined die recipients. suggest objective scoring systems, rather subjective assessments, accurate evaluation.42Cheng Scholar,43Harhay “prehabilitation” physical functioning sufficiently allow transplant. tools posttransplant patients. pandemic created new emphasis remote awaiting offer.9Lentine •Optimize eliminate frailty, deficiencies adequate grounded eligibility referring clinicians.•Develop assist minorities, reach waitlis