KDIGO Clinical Practice Guidelines for the Care of the Kidney Transplant Recipient

Transplantation: What 2008 has in Store

Transplantation: What 2008 Has in Store

Gigi Politoski, SVP for ProgramsDawn Townsend, Director,

US Transplant games


KDIGO Clinical Practice Guidelines for the Care of the Kidney Transplant

Recipient

• Transplant recipients carry the burden of disease over to transplantation

• Transplant recipients still may have CKD based on their GFR

• Transplant recipients need to be managed based on their stage of CKD



Recipient

• Transplant Center/Surgeon may operate under “you’re fixed” and focus more on immunosuppressive therapy

• Community nephrologists knows how to manage, but don’t for fear immunosuppressive may be compromised

Who’s responsible for the care?



Recipient

• Immunosuppression• Graft monitoring and infection• Cardiovascular disease and risk factors• Malignancies and other considerations

Main Content Topics:


Immunosuppression

• Initial (Induction) Immunosuppression• Maintenance Immunosuppression• Monitoring • Acute Rejection


Graft Monitoring and Infection

• Treatment of Chronic Allograft Injury• Recurrent Kidney Disease• Monitoring of Kidney allograft Function• Vaccination and Treatment of Infectious

Diseases


Cardiovascular Risk

• Management of Hypertension and Dyslipidemias

• Diabetes• Obesity• Tobacco Use


Malignancies and Other Considerations

• Cancer of the Skin, Uterus/Cervix, Breast, Prostate, Colorectal, Hepatocellular, Kidney

• Bone Disease, Anemia• Pregnancy• Growth and Development in Children


KDIGO Clinical Practice Guidelines on Care of the Kidney Transplant

Recipient

• Public Review in June 2008• Published in December 2008• Implementation will begin December

2008/ January 2009

Timeline:


Kidney Allocation Review Policy (KARS)

• OPTN/UNOS is reviewing the allocation system for deceased donor kidneys

• NKF and other organizations, constituents asked to provide feedback during the policy development process

• Concept of “net survival benefit” or prediction of LYFT: Life Years From Transplant, increasing the number of extra “life years” gained by transplant


Kidney Allocation Review Policy (KARS)

• LYFT variables considered: age, time exposed to ESRD, BMI, diagnosis, previous transplant, other factors

• Disadvantages: LYFT varies greatly by age, diabetes• Advantages: LYFT is similarly distributed by race,

gender• Unknown: Impact on living donation? (Younger

patients who are more likely to have potential living donors will receive more of the available deceased donor kidneys?)

• A final policy proposal has NOT been finalized yet


Transplant Tourism and Payment for Organs

• The World Health Organization (WHO) estimates that organ trafficking accounts for 5-10% of kidney transplants worldwide

• Pakistan: at least 2,000 Pakistanis have donated kidneys to “transplant tourists”

• India: In poverty-stricken Chennai, 90 tsunami survivors have sold their kidneys but did not receive the payment promised to them. In Bangladesh, human kidneys, livers and corneas are for sale.

• India: An illegal kidney transplant racket recently uncovered. Hundreds of poor laborers forced or duped into donating to wealthy foreigners.

• Philippines: destination country for transplant tourists• Recipients from the Gulf Region, Asia and North America


Transplant Tourism and Payment for Organs

• China: The national government enacted legislation in 2007 which has reduced the rate of executions in China (and the organ transplant rate) substantially. Transplant tourists are now seeking other destinations.

• The World Health Assembly urges its member states to “take measures to protect the poorest and vulnerable groups from transplant tourism and the sale of tissues and organs, including attention to the wider problem of international trafficking in human tissues and organs”.

• NKF remains opposed to transplant tourism and payment for organs.


NKF Advice to Potential Donors and Transplant Candidates

• Potential non-directed living donors: work through a transplant center to be matched to an appropriate recipient (not try to find a recipient on their own).

• Transplant candidates are discouraged from traveling overseas for transplantation

• Dangers to both living donors and recipients (poor medical outcomes, infection or disease transmission, lack of follow-up care).


NKF Advice to Potential Donors and Transplant Candidates

• Most transplant candidates find a living donor among someone they already know– or someone in their community.

• The best strategy is to let the community (family, friends, acquaintances, co-workers, their religious community or social clubs) know about their need for a transplant and options available (living vs. deceased donor)

• See NKF’s “Suggested Process for Potential Non-Directed Living Donors” and “Waiting for a Transplant”


National Living Donor Assistance Center (NLDAC)

• Administered by the DoT through a cooperative agreement with the University of MI and the ASTS

• Mission is to reduce the financial disincentives to living donation

• Reimbursement for travel, hotels, meals, other non-medical expenses incurred by living donors/potential donors

• Priority is given to individuals not otherwise able to afford the expenses


National Living Donor Assistance Center (NLDAC)

• Provides up to $6,000 per donor• Transplant centers must register with NLDAC

and submit applications on behalf of potential donors

• 232 transplant centers have registered• NKF has been asked for input and

recommendations• Visit www.livingdonorassistance.org or call

703.414.1600


Paired exchange

Donor 1

Donor 2 Recipient 2

Recipient 1

NOT compatible

NOT compatible

OPTN/UNOS data (based on available data

as of 1-4-08):

260 paired exchanges have been completed in the U.S. (520 transplants)

60 U.S. transplant centers have performed paired exchanges


Emerging Trends in Kidney Exchange

• New websites & organizations being established to try to facilitate exchanges

• OPTN/UNOS involvement?

• Increasing numbers of 3-way, 4-way exchanges…

Optimization: a branch of mathematics that calculates which decisions will give the most benefit from a limited resource. This technology is already used in:

• Airline scheduling • Stock portfolio management • Mapping driving directions • Residency matching


Optimization In Paired Donation

The resource: is the pool of willing (but incompatible) donors.

The decision: Which incompatible pair should be matched with which other incompatible pair? Some pairs could be matched with many different pairs.

Optimization could mean hundreds more patients per year will receive a kidney.*

* www.optimizedmatch.com


Math meets medicine* Optimizing the match

Each number represents a recipient & his/her incompatible donor (40 incompatible pairs, numbered 0-39).

Each line indicates 2 pairs (4 people) who would be compatible for paired exchange.

* Math News, Vol 5, Issue 2


Math Meets Medicine: Optimizing the match

How do you decide which series of matches would yield the most transplants?

Example:

Pair 22 is compatible with Pair 38.

A paired exchange takes place between these 4 people (without considering all possible combinations first).


Math meets medicine Optimizing the match

Outcome:

Pair 22 and Pair 38 have been matched in a paired exchange.

But strategically, these pairs were the wrong choice for a match. Many of the matches (previously possible) have been lost.

A “bad match” can significantly affect opportunities for everyone else…


Optimizing Matching of 8 Pairs


Number of Transplants Versus Quality of The Match

4 matches - 50 points 3 matches - 60 points


Recipient 2Recipient 1

Non-directed donor

Donor 1

NOT compatible

Donor 3

Recipient 3

Donor 2

NOT compatible

NOT compatible

Chain continues

Never Ending Altruistic Donor Chain (NEAD): Utilizing Optimization

The last potential donor in the chain becomes a non-directed donor in a new chain.


Early and Pre-emptive Transplant:

Crucial to NKF’s Strategic Plan• Board of Directors Decision

• Professional and Patient Surveys

• Controversies Conference held (March 2007)

• Publication pending in (CJSAN 2008)


Nephrologist Survey ResultsPradel, Jain, Mullins, Vassalotti, Bartlett

• 5,911 nephrologists contacted • 476 or 8% responded • 71% believe that preemptive transplant is the

best• 26% believe that nephrologists should educate

CKD patients• 19% believe that pre-emptive transplant would

increase the demand for deceased kidney donors • 25% felt dialysis centers would lose revenue

referring preemptively• 47% agreed there is a need to develop practice

recommendations


Patient Survey

Purpose of Survey was to determine: • Why persons with CKD delay transplantation• What education they received about the transplantation option• How to educate patients about living donation and transplantation

Objectives of Study were to determine: • When and from whom do patients learn about transplant, living

donation and treatment options? • What barriers do patients face in pursuing early transplants?• What do patients fear about transplantation and living donation? • How does this impact high risk groups (African Americans, rural, re-

transplant)


Patient Survey Findings

• 518 responses (15% of random sample, IMIS)

• 76% (316) had kidney transplant• 24% (101) have CKD (no transplant) • 22% (92) are high risk


Patient Survey Findings (continued)

Patients Want to Learn More About:• How to work the system 76%• Information about donor 55%• Potential for returning to dialysis

42%• Finances, Medicare 41%• How to evaluate treatment options

37% • How long kidney will last 35%• Meds side effects 28%• Impact on Quality of Life 23% • Risks involved 20%

Patients Worry About:• Medical Costs 70%• Don’t want to ask for a

living donor 62%• Costs to living donor 61%• Health of living donor 56%• Affording medications 48%• Scared of surgery 40%• Don’t want people to know

I’m sick 36%• Needing to be on dialysis

before transplant 26%• Anti-rejection drugs 26%


Patient Survey Findings (continued)

• Almost half of respondents without a transplant never discussed this option.

• The discussion came too late for many who did discuss it.

• Doctors were not initiating this discussion and patients and were not the first to bring up the topic to patients (probability for misinformation from unreliable sources).


KDOQI Early Transplant Conference

March 2007 in Alexandria, VAChairs: Robert Gaston, Stephen BartlettParticipants: 60 nephrologists/surgeons

experts

Conference Recommendations (CJASN)


Topline Summary

Benefits: Barriers:• Less interruption to

employment and home

• Better outcomes: longevity and quality

• Avoid medical complications of dialysis

• Avoid costs associated with initiation of dialysis (vascular access)

• Medicare may not cover early evaluation or surgery

• Finding a living donor

• Being ready psychologically, financially, socially

• Access to doctors knowledgeable about the transplant option


Early Transplant Initiative

• Primary care MDs Lab reporting of eGFR Improved education regarding CKD and the benefits

of early referral for nephrology co-management • Nephrology

Develop multidisciplinary CKD clinic Coordinate evaluation with transplant centers to

facilitate efficient care Improve access for new referrals Develop strategies to expand nephrology manpower

• Collect and report nephrologists’ and dialysis units’ transplant referral rates

Recommendations to Address Physician Barriers to

Preemptive Transplantation:


Early Transplant Initiative

• Highlight transplantation in CKD management education

• Encourage multidisciplinary CKD care• Psychosocial support for patients and families during

the evaluation process• Public education- World Kidney Day• Support and resources for living donor expenses• Expanded insurance coverage for early transplant

evaluation and assessment

Recommendations to Address Patient Barriers to Preemptive Transplantation:


Early Transplantation Initiative

• Create an implementation plan• Seek collaboration with other interested

groups• Begin a dialog with transplantation

societies• Develop resources and pilot test

Next Steps

Documents

KDIGO Clinical Practice Guidelines for the Care of the Kidney Transplant Recipient