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Paired exchange and Chain Donor Transplants: Decrease the Waitlist & Manage Center Finances. Jeffrey Veale, M.D., Kidney Transplant Surgeon, Director of the Donor Exchange Program, Assistant Professor - UCLA Medical Center Debbie Mast, Financial/Database Manager, Stanford Hospital and Clinics

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paired exchange and chain donor transplants decrease the waitlist manage center finances
Paired exchange and Chain Donor Transplants:Decrease the Waitlist & Manage Center Finances

Jeffrey Veale, M.D., Kidney Transplant Surgeon, Director of the Donor Exchange Program, Assistant Professor - UCLA Medical Center

Debbie Mast, Financial/Database Manager, Stanford Hospital and Clinics

Sean Van Slyck, Director of Procurement, CTDN

questions to run on
Questions to run on:
  • Is my Transplant Center exploring all possibilities in decreasing the wait list, including paired and chain donation?
  • What opportunities/barriers to success do

I see in the paired/chain donor process?

  • How can your OPO assist with paired exchanges/chain transplantation?
the problem
The Problem

Kidney Exchanges…A New Paradigm

  • 80,000 people awaiting kidney transplants
  • 16,000 transplants performed yearly
  • List continues to expand secondary to obesity, diabetes and old age
possible solutions
Possible Solutions
  • Prolong allograft longevity
    • Calcineurin inhibitor free protocols
    • Immune monitoring
  • Expand the donor pool
    • Xenotransplantation
    • Paying donors
    • Accepting marginal kidneys (ECD, DCD…)
    • Utilizing incompatible donors
utilizing incompatible donors
Utilizing Incompatible Donors
  • At least one third of patients with a willing living donor are excluded due to blood type and cross match incompatibility
  • JAMA 2005
    • 35% of any two individuals will be ABO incompatible
    • 30% of recipients sensitized to allo-HLA due to previous transplants, pregnancies or transfusions
options
Options
  • Desensitization programs
  • Paired donor exchanges “SWAP”
  • Chains
  • Combination (of the above)
desensitization programs
Desensitization Programs
  • Advantages
    • Expands the donor pool
    • Friend/loved one donates to intended recipient
  • Disadvantages
    • Very expensive – Additional $28,979 (JAMA 2005)
    • Decreased graft survival rates (AJT 2004, 2009)
      • 1 yr 84% (vs 96%)
      • 5 yr 69% (vs 81%)
    • Decreased patient survival rates (AJT 2004)
      • 5 yr 87% (vs 94%)
paired donor exchanges swap
Paired Donor Exchanges “SWAP”
  • First U.S. exchange performed under little publicity in 2000 at Rhode Island Hospital
  • Slow to catch-on due to NOTA 1984 “unlawful to acquire organ in exchange for valuable consideration”
  • Johns Hopkins and University of Cincinnati early pioneers
  • Office of legal counsel “exchanges do not violate NOTA” March 28, 2007
  • Opened the door for UNOS and individual centers to develop donor exchange programs
paired donor exchanges swap11
Paired Donor Exchanges “SWAP”
  • Advantages
    • Expands the donor pool
    • Greater sense of satisfaction by helping 2 recipients
  • Disadvantages
    • Donors anesthetized simultaneously
    • Donors typically travel
    • Challenging logistics
      • Multiple operating rooms, surgeons, nurses…
    • Compared to chain transplantations
      • Decreased quality of matches
      • Decreased quantity of matches

D

D

R

R

chains
Chains
  • Concept first proposed by Dr. Michael Rees, a Urologist at the University of Toledo
  • First U.S. chain launched in July 2007 and thus far has facilitated 10 transplantations involving six transplant centers in five different states
  • First California chain launched in July 2008 and thus far has facilitated 8 transplantations involving 4 transplant centers in two different states
    • First transcontinental transplant chain
    • First “out-of-sequence” transplant chain
slide15

Altruistic Donor

New York, NY

July 30, 2008

D1

Cousin of R1

Los Angeles, CA

R1

Los Angeles, CA

July 24, 2008

D2

Husband of R2

Los Angeles, CA

R2

Los Angeles, CA

July 24, 2008

D3

Son of R3

Los Angeles, CA

R3

Los Angeles, CA

October 2, 2008

D4

Wife of R4

Los Angeles, CA

R4

Los Angeles, CA

October 2, 2008

D5

Husband of R5

Los Angeles, CA

R5

Los Angeles, CA

November 19, 2008

D6

Wife of R6

Palo Alto, CA

R6

Palo Alto, CA

November 19, 2008

D7

Wife of R7

New York, NY

R7

New York, NY

November 19, 2008

D8

Brother of R8

San Francisco, CA

R8

San Francisco, CA

To be scheduled

The chain

may continue

chains16
Chains

D

D

D

D

  • Advantages
    • Potential for the largest expansion of the donor pool since the landmark brain death act in 1981 (UDDA)
    • Great sense of satisfaction for donors
      • Helping multiple recipients
      • Additional patients on the waiting list move up and into the newly vacated spots
    • Easier Logistics
      • Donors don’t need to be anesthetized simultaneously
      • Donors don’t need to travel
      • If donor fails to donate, chain ends but no irreparable harm to recipient

R

R

R

slide19

28.0

Deceased Donor Kidneys

Living Donor Kidneys

17.8

14.2

10.5

7.8

7.1

Standard

Criteria

Donors

0-5

Antigen

Match

Standard

Criteria

Donors

6

Antigen

Match

Extended

Criteria

Donors

0-5

Antigen

Match

Extended

Criteria

Donors

6

Antigen

Match

Living

Donors

0-5

Antigen

Match

Living

Donors

6

Antigen

Match

Clinical Transplants 2005

chain
Chain
  • Disadvantages
    • Donate to a stranger instead of your loved one
      • Some argue an advantage, as greater emotional reward knowing multiple recipients benefit from donation
    • Billing
      • Problem essentially solved (Debbie Mast and Nanci Flores)
    • Requires transplant centers to adopt a new attitude
      • Cooperation between centers rather than competition
      • Shipping living donor kidneys
software matching options
Software-Matching Options
  • Johns Hopkins
  • New England Program for Kidney Exchange (NEPKE)
  • Paired Donation Network (PDN)
  • Alliance For Paired Donation (APD)
  • Silverstone Solutions-Matchmaker
  • National Kidney Registry (NKR)
national kidney registry
National Kidney Registry
  • No cost
  • 30 centers across the United States
  • California Members include:
    • CPMC, Stanford, UCLA, UCSF (Sharp Memorial?)
  • Aetna=2,500 patients on deceased donor waiting list
  • Superior matching software
  • Facilitated the most chain transplantations (51 thus far)
step 2
Step 2
  • Enter pair into the National Kidney Registry
    • www.kidneyregistry.org
    • Phone 1-800-936-1627
  • No cost
  • No identifiers required
    • Donor/recipient, age, blood type, HLA antigens and antibodies
step 3
Step 3
  • Matches will be arranged
  • Communication between centers is key
    • Coordinators - arrange records to be exchanged and confirm details
    • Surgeons - trust one another
    • OPOs - transport living donor kidneys
a new paradigm
A New Paradigm
  • At least one third of patients with a willing living donor are excluded due to blood type and cross match incompatibility
  • This is the first opportunity to substantially increase the donor pool by utilizing high quality organs, rather than merely accepting more organs of uncertain caliber (ECD, DCD…)
slide27
“When will the transplant societies, government agencies or society as a whole realize that we are mired in old paradigms. Attitudinal changes must take place to truly increase donation of high quality organs to make an impact on those dying on the waiting list”
    • Bromberg and Halloran (AJT 2009; 9: 11-13)
living donor transplantation medicare guidelines
Living Donor Transplantation – Medicare Guidelines

Medicare guidelines overshadow all the financial aspects of kidney transplantation

Pre-entitlement vs. entitlement to Medicare

Pre-entitlement: a person with end-stage renal disease who does not yet have Medicare

Entitlement: a person who has Medicare eligibility

Based on the guidelines, all pre-transplant services for pre-entitled or entitled recipients are charged to the “kidney acquisition” cost center. Donor services are then charged to the “recipient” transplant center (services prior to the admission for organ procurement). Following admission, hospital services are billed to cost center and physician services are billed to recipient insurance.

living donor transplantation medicare guidelines30
Living Donor Transplantation – Medicare Guidelines

Guidelines were written with the presumption that both the recipient and donor are housed in the same facility.

*Internal pairs – fits this scenario

*External pairs/chains – do not fit!

WHAT DO WE DO NEXT?

We reviewed the Interpretive guidelines in detail and charted out the billing based on current regulations and providers of care for these paired and chain donors…

how do we do it
How do we do it?
  • Work closely with YOUR clinical team-you need to know what they know, when they know it!
  • Work closely with administrative, financial, and contracting teams from involved centers to ensure letters of agreements in place, insurance information is shared, and authorizations in place.
  • Determine capabilities of your facility’s billing system to ensure anonymity of donor/recipient relationships.
  • Most of all, have a sense of humor as you work out the logistics and be proud of YOUR work in reducing the wait list!
how your opo can help you
How your OPO can help you
  • Logistical support for organ transportation
    • Arrange all courier needs
    • Door-to-door service
  • Perfusion, packaging and labeling support
    • Recovering center responsible for perfusate
    • Supply all packaging and labels
    • A coordinator to ensure adherence to UNOS packaging rules
  • An ABO verification page
  • A worksheet documenting all recovery timing and anatomy.
what your opo will need
What your OPO will need
  • Once the exchange is confirmed contact the OPO
  • Be sure you have your UNOS ID and ABO verification complete
  • Provide the OPO with the relevant info
    • Date/time of procedure
    • Accepting program and contact info
    • Donor Info (UNOS ID, ABO, DOB, etc)
  • Provide the OPO with a copy of the donor chart to package with organ
suggestions for a successful process
Suggestions for a successful process
  • Conference calls with all involved parties (surgeons, coordinators, OPO)
    • At least one conf call a week prior
  • Contact between the sending OPO and the OPO of the receiving transplant center
  • Provide a final, written summary of logistics to all parties 24-48hrs prior to case
  • Back-up considerations
financial considerations
Financial Considerations
  • OPO costs passed along to the transplanting center
    • Minimal packaging costs
    • Minimal staff costs
    • Primarily courier costs
  • OPO costs absorbed by the OPO
  • OPO charges a full SAC fee