Table 2.

Proposed policies to incentivize transplant centers to accept kidneys with a high KDPI or designated by the PHS as increased risk for blood-borne viral infection

Current BarrierNew IncentivesChallenges to Successful Implementation
Acceptance of high KDPI kidneys imposes additional costs for centers, such as perioperative complications requiring treatment and longer length of stay.Medicare and other payers should reimburse at higher rates for higher-risk kidneys.Payers have not historically embraced risk-adjusted payment structures.
Kidney allocation rules should be changed so that centers that achieve good outcomes with higher-risk kidneys subsequently get priority for higher-risk kidneys.This approach would require new changes to the national allocation system.
Kidney allocation rules should be changed across all organ procurement organizations so that when a donor is identified whose kidneys are at highest risk for discard, centers can use the pair of kidneys for one recipient.If kidneys at risk for discard are not accurately identified, one patient may get two kidneys where two patients might have instead benefitted.
Transplant centers are penalized for worse-than-expected patient and allograft survival after transplantation.Calculation of center survival outcomes should exclude patients who received the lowest-quality kidneys.Potentially valuable information about center performance would not be included in the survival statistics.
Report cards should include an “organ acceptance metric” which would reward centers for accepting higher-risk organs.The organ acceptance metric would require careful risk adjustment for organ quality and the center population.
Each year, regulatory organizations should recognize and/or reward centers that aggressively accepted organs.The organ acceptance metric might put pressure on centers to accept lower-quality kidneys for patients that would be better served by waiting longer for a higher-quality organ.
It is unknown how to optimally design this recognition or reward to change center behavior.
High KDPI and PHS infectious risk kidneys are often turned down by many patients, leading to prolonged cold storage and eventual discard.Novel methods for prospective informed consent should be developed, such that patients are consented on the waiting list for lower-quality organs and minimal additional consent is required at the organ offer; kidneys are accepted quickly.Transplant clinicians may feel that obtaining a second consent at the time that an organ is offered is necessary to protect them from subsequent liability.
  • Note that higher KDPI kidneys have an elevated estimated rate of graft failure. PHS infectious-risk kidneys, such as a kidney donated by an individual with an injection drug-use history, pose slightly higher risks of viral transmission (such as HIV) compared with other kidneys).