Issue: November 2020
Disclosures: Disclosure: Cooper reports no relevant financial disclosures.
November 12, 2020
5 min read

Advancing American Kidney Health can improve the transplant rate

Issue: November 2020
Disclosures: Disclosure: Cooper reports no relevant financial disclosures.
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Transplant is widely considered the preferred modality of renal replacement therapy for patients with irreversible kidney failure.

Transplant is more effective at replacing kidney function than dialysis and provides most patients with a better quality of life, as well as an increased opportunity to participate in the work force.

Despite the advantages offered by transplant, fewer than one in 10 adults with kidney disease receive a kidney and 12 candidates die each day on the waitlist. Policy makers must take aggressive measures to help more patients seek a transplant and increase the number of available kidneys.

Advancing American Kidney Health

In July 2019, the Trump administration launched Advancing American Kidney Health (AAKH). This comprehensive strategy to transform chronic kidney disease care contains three major goals to reduce the incidence of kidney disease and dramatically change the modality of treatment for end-stage kidney disease. Two of these goals would double the number of kidneys available for transplant by 2030 and have 80% of incident patients with ESKD by 2025 treated with home dialysis or receive a transplant.

AAKH established five new payment models to help shift patients toward home dialysis and transplantation and away from in-center dialysis as the default treatment option. In addition to enhancing patient choice, increased home and transplant therapy is expected to generate savings to Medicare compared to in-center dialysis.

Matthew Cooper

The ESRD Treatment Choices (ETC) model, which was finalized in a rule announced on Sept. 18, is mandatory and consists of payment adjusters based on utilization of transplant and home dialysis. The ETC model will increase the ability of patients to access transplant and home dialysis, both of which are the preferred course of kidney replacement therapy for many patients but are vastly underutilized in the United States. While the proposed rule would have used actual transplant rates, including from deceased donors, in the new requirements, the final rule consists of the waitlist rate and the living donation transplant rate.

While encouraging patients to consider home dialysis and kidney transplant is laudatory, it is imperative health care teams provide appropriate education for patients and avoid coercion into home therapy or transplant merely to meet the AAKH goal requirements.

OPO performance

Educating and assisting patients to seek kidney transplantation is but one step to provide an alternative to dialysis. Adding more names to the waitlist without increasing the number of donated kidneys serves no benefit. The AAKH includes a proposal for new regulations to improve performance for OPOs. Variability in performance, including low performing OPOs in many instances, has received considerable attention from the transplant community, patient community and mainstream media. The consensus is the metrics used to evaluate performance are flawed, particularly the donation metric (the number of organs recovered with the intent to transplant as compared to “eligible deaths”).

The donation metric denominator of “eligible deaths” is based on unaudited self-reported data by OPOs, resulting in ambiguous, noncomparable statistics on donor data that often provide a distorted picture of individual OPO performance. Utilizing data that are contemporaneous, accurate, independently verified and readily accessible to develop a revised OPO donation metric can provide a benchmark and allow for comparisons of OPOs, providing patients with a better understanding of OPO performance, its impact on wait times and a more accurate understanding of the likelihood of transplant. In addition, development and analysis of a more reliable and comparative metric would allow the sharing of best practices between OPOs for an overall increase in donor volumes which, all agree, is a shared goal.

Responsibility, however, does not solely rest with the OPO. Transplant centers must be held to increased accountability to ensure the organs procured by OPOs are transplanted as current allocation policy dictates.

Improve organ utilization

In May 2017, I co-chaired the National Kidney Foundation’s Consensus Conference to Decrease Kidney Discards. More than 70 donation and transplant experts, including past kidney recipients and those currently on the waiting list, gathered to discuss possible solutions to increase utilization of donated kidneys. More than 3,500 kidneys procured from deceased donors are refused by transplant centers and subsequently discarded by OPOs each year.

While appreciating that not all are transplantable organs, many of these discards could provide a viable new kidney for someone on the waitlist who otherwise probably will never be among the one in 10 who are transplanted. Importantly, data have shown patients are often unaware that organs allocated to them have been rejected by their transplant center and sadly, may never receive another offer. Underperformance by some OPOs, coupled with the acceptance and transplant rate of certain transplant centers, illustrate the overall need for greater transparency in organ donation and transplant for patients and their families.

Immunosuppressive drugs

Increasing the number of kidney donations usually is the first thing that comes to mind when discussing opportunities to provide more transplants. However, it is equally important to ensure graft survival of the new kidney, which requires strict adherence to daily immunosuppressive therapy. Anyone who has been involved in kidney or transplant public policy is aware of Medicare’s 36-month post-transplant limit on coverage for immunosuppressive drugs for young, non-disabled kidney recipients.

In January, I testified before the U.S. House of Representatives’ Energy and Commerce Committee Subcommittee on Health in support of H.R. 5534, the Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act of 2019. As a transplant surgeon, it is awkward for me to encourage the gift of life from donor families or from living donors while knowing Medicare policy might limit a patient’s access to immunosuppressive drugs, which almost absolutely results in graft failure.

Nearly 120 bipartisan members of Congress have co-sponsored this legislation and the Congressional Budget Office estimates extended coverage would result in a net savings to Medicare of $70 million in the first 10 years, saving on the exorbitant costs of maintenance dialysis. It is time for Congress to remedy this flawed policy.

National Living Donor Assistance Center

People from struggling socioeconomic groups, which often include racial and ethnic minority communities, face significant economic barriers to living donation from unreimbursed expenses, such as travel, time off work, child care, and other costs that often prevent willing and able living donors from coming forward.

Congress created the National Living Donor Assistance Center to help address these financial barriers. Based on the final rule released on Sept. 18, living donors will be eligible for up to 4 weeks of reimbursement for lost wages, child care and elder care associated with surgery and recovery, with an additional 2 weeks if health complications occur. The final rule also increases the household income eligibility threshold for living donors and recipients from 300% of federal poverty guidelines to 350%.


The kidney community is encouraged by the release of the final rules and the prospect of indefinite immunosuppressive coverage, while concurrently appreciating that the success of all these opportunities and interventions demands the collaborative effort of all. Time has long passed whereby the “problem” of organ donation and transplantation can be solved via a single intervention nor is it someone else’s problem to solve. The success we all seek will only be possible with collaboration, sacrifice and a better appreciation of how each component of this complex infrastructure must work together for the good of the patients we serve.