Medical Board Policies

Voucher Program

The Voucher Program is a paired exchange separated in time.

  1. General
    1. A voucher donor that starts a chain does not increase a Member Center’s net chains started (NCS) score.
    2. A voucher holder that receives a kidney does not decrease a Member Center’s net chains started (NCS) score.
    3. There is no guarantee that a voucher holder can be matched or transplanted.
    4. The voucher donor and voucher holder can be at different voucher participating centers.
    5. Donation ranges for voucher donors will be limited to 6 weeks.
  2. Voucher Types
    1. Standard Voucher: May identify one patient as an intended recipient for a voucher who is in imminent need (within 12 months) of a transplant. Standard voucher donors may also name up to five family members as backup voucher holders should the initial voucher holder receive a deceased donor transplant. 
    2. Family Voucher: May identify up to five family members for vouchers, none of whom are in imminent need of a transplant. Only one voucher can be redeemed per family voucher kidney donation.
    3. Swap Saver: A donor proceeds with donation to keep the rest of a chain intact even though their paired recipient patient has been removed from the chain due to a swap failure. The paired recipient patient is provided a voucher for their paired donor’s donation.
    4. Real-Time Swap Failure: Occurs when a swap fails after one or more of the donor surgeries has begun. When a swap fails in real time, the stranded patient is provided a voucher.
  3. Voucher Activation: Centers may activate a voucher holder for matching once all of the following requirements are met:
    1. The voucher donor has donated.
    2. Both the voucher donor and voucher holder informed consent documents have been successfully uploaded to the NKR.
  4. Fast-Track Voucher Activation: This allows a patient to be activated for matching at the same time as the donor. In these cases, the patient could receive a match offer before the donor is matched. Centers may fast-track standard voucher activation under the following conditions:
    1. The transplant center is a Partner Center in good standing.
    2. Both the voucher donor and voucher holder informed consent documents have been successfully uploaded to the NKR.
    3. The standard voucher donor has completed the workup and is fully cleared for donation.
    4. The standard voucher donor is activated for matching with a surgery date range of 21-42 days.

Guidelines

  1. Voucher holder patients shall be prioritized over paired recipient patients.
  2. Paired wait time shall not carry over to voucher wait time if the pair converts to a voucher.
  3. When adequate time is not available or there are other important considerations, match offers shall be selected to maximize the probability that the swap will be successful while maximizing the total number of transplants facilitated.
  4. Chains starting with O blood type donors will generally end with O blood type voucher holders.
  5. Age-Appropriate Matching: O blood type patients will generally not be matched with donors who are more than 10 years younger.
  6. Size-Appropriate Matching: O blood type patients will generally not be matched with donors who are more than 6 inches taller.
  7. Time on dialysis may be used as a tiebreaker when other match offer selection criteria are similar.
  8. Low eplet mismatches may be used as a tiebreaker when other match offer selection criteria are similar.
  9. The Member Center’s targeted chain end (TCE) score is displayed in the center portal and provides details on all TCE calculations.
  10. The Member Center’s compatible pair ratio (CPR) score is displayed in the center portal and provides details on all CPR calculations.
  11. The net chains started (NCS) usable score is defined as the number of non-directed donor (NDD) chains a center has started less the number of chain end wait list kidneys the center has received.
    1. A Member Center’s NCS score shall be decremented when it receives a kidney from the NKR even if the kidney does not function.
    2. The surgical committee has the option to transfer the NCS decrement from the recipient center that utilized the kidney to the donor center, if the recipient surgeon can demonstrate to the surgical committee that the graft failure was clearly the result of an impaired kidney delivered to the recipient center.

Match Offers

Match offers shall be prioritized based on the following scientific and objective criteria:

  1. Any living kidney donor that donated in an NKR swap.
    1. Direct donors utilizing Donor Shield Direct do not donate in an NKR swap.
  2. Hard to match patients.
    1. Generally defined as having an estimated wait time >= 6 months.
  3. Voucher patients:
    1. Compatible voucher holders
      1. Compatible combos using biological compatibility formula.
    2. Special voucher holders (not in 3a above)
      1. 6+ month voucher wait time.
      2. 21 years of age and younger.
      3. 24+ month donation lag time.
      4. Replacement (90 day and primary non-function).
    3. Regular voucher holders (not in 3a & 3b above).
      1. Patients at Member Centers >= 40% compatible pair ratio (CPR).
      2. All remaining non-O blood type patients (not in 3a & 3b above).
      3. Real-time swap failure patients (includes swap savers).
    4. General voucher holders (not in 3a, 3b, & 3c above).
  4. Paired patients
    1. Compatible pairs.
    2. NKR paired wait time.

Chain End Wait List Offers

When a voucher holder cannot be matched at the end of a chain, the following priorities shall generally apply:

  1. Member Centers with a wait list decline ratio < 30% and net chains started score > 0.
  2. Partner Centers with a wait list decline ratio < 30% and a targeted chain end Score > 0.

Photographing Kidneys

Pictures of all shipped kidneys shall be sent to the recipient surgeon after a phone call or text to the recipient surgeon, both within 1 hour of the completion of the surgery. Pictures shall be taken on the back bench after flushing and shall include:

  1. Allograft parenchyma (demonstrating kidney is well-flushed ‘blanched’)
  2. Any abnormalities (such as cysts, lesions, capsular tears, surgical injuries, etc.)
  3. Renal hilum (highlighting vessel length, multiple vessels and/or ureters). If the kidney is declined after delivery to the recipient center, the recipient center must send pictures of the kidney to the NKR within 2 hours of receipt of the kidney.

Managing Real-Time Swap Failures

A real-time swap failure occurs when a swap fails after one or more donor surgeries have begun. When a swap fails in real time, the NKR shall:

  1. First attempt to cancel or reschedule the swap.
  2. If any of the donor surgeries cannot be aborted, the NKR Member Centers shall proceed with the swap and the NKR shall work to end a chain to the patient in the failed swap that did not receive a kidney.
  3. The center caring for the patient that did not get a kidney must remove all restrictive preferences and accept all viable donors via the donor pre-select function, unless the center determines that it is in the patient’s best interest (e.g., pre-emptive transplant) to wait longer by declining viable potential donors in order to get a better match.
  4. If the patient that did not get a kidney is hard to match (generally defined as having an estimated wait time >= 6 months), the NKR may not be able to find a compatible donor for that patient. This risk must be disclosed in the Member Center’s informed consent documentation that is signed by the patient and the donor.
  5. In the calculation of net chains started, the donor center is accountable for the chain break.
  6. If the real-time swap failure was caused by the recipient center’s decline of the kidney after the start of the donor surgery, the NKR shall attempt to place the kidney in accordance with the Medical Board Policies.
    1. If the NKR is unable to place the kidney it will remain at or be shipped back to the donor center for transplant into a waitlisted patient.
    2. If the kidney does not remain at the donor center, the new recipient center will be responsible for all transportation costs.
  7. Per OPTN policies, real-time swap failures are reportable events.

Replacement Case Details

  1. Any standard voucher holder, family voucher holder, or paired recipient receiving a kidney in an NKR facilitated transplant who:
    1. Experiences primary non-functioning where the kidney never worked and/or the recipient was never removed from dialysis, which is reported to the NKR within the first 90 days post-transplant, will be targeted for a chain end kidney if they desire another living donor transplant. Waitlist recipients and direct donation recipients are not eligible for this replacement policy.
    2. Experiences graft failure within 90 days of the transplant and meets the conditions below:
      1. Center reports the issue in the NKR swap quality system and provides pictures of the kidney within 8 hours of kidney receipt will be provided a replacement kidney if the surgical committee, following review of the data and circumstances, clearly and confidently determines the graft failure was a result of an impaired kidney that was delivered to the recipient center. Center reports the issue in the NKR swap quality system after 8 hours but within 90 days of kidney receipt may be provided a replacement kidney if the recipient surgeon presents the case and the surgical committee determines that the graft failure was clearly and confidently a result of an impaired kidney that was delivered to the recipient center. Waitlist recipients and direct donation recipients are not eligible for this replacement policy.

Member Center Suspension

The NKR reserves the right to suspend Member Center participation if the Member Center is deemed to have introduced safety risks or is in violation of Member Center Requirements. Suspension shall continue until appropriate corrective action plans have been provided and all issues that caused the suspension have been rectified.