Moving toward preemptive kidney transplants

A costly condition

For patients with end-stage renal disease (ESRD), also known as end-stage kidney disease (ESKD), treatment typically follows a well-worn path: the condition is diagnosed with a stage assigned, the patient begins dialysis and adjusts to making that grueling process routine — often for years — as they wait and hope for a kidney transplant. Only about one-fifth of the 110,000 patients awaiting a kidney will receive one in any given year.¹

Yet it is possible for patients with chronic kidney disease (CKD) to begin the transplant process and to possibly receive a preemptive transplant before starting dialysis. According to the National Kidney Foundation, preemptive transplants (those that occur before dialysis) and early transplants (which occur after only a brief time on dialysis) offer significant benefits.² These benefits include higher quality of life, lower risk of organ rejection, fewer dietary and lifestyle limitations and fewer strictures.

There is also the potential for significant health care savings. It’s estimated that preemptive kidney transplants avoid $500,000 in health care costs over the course of a patient’s ESRD journey, largely from inpatient stays and lengthy dialysis.³ And Optum Health data shows that the cost of the transplant is typically offset in less than seven months, with a net savings of $101,800 in the first year alone.⁴

Still, the preemptive approach remains stubbornly rare, with only 2.5% of U.S. kidney transplants performed before dialysis begins.⁵ Why? The challenges are complex and varied. But that doesn’t mean real progress isn’t being made toward finding life-saving solutions.

Frustrations in match-making

Organ transplants require not just a match between donor and recipient, but also a doctor to facilitate that match. When a nephrologist is brought into a patient’s care late in their disease, the opportunity to make a referral to a transplant clinic and pursue a preemptive approach is largely lost. As researchers note in the Clinical Journal of the American Society of Nephrology, “It is almost impossible to accomplish preemptive transplantation without substantial pre-ESKD care by a nephrologist.”⁶

But connecting with a nephrologist before renal disease becomes late stage is hardly guaranteed. Patients may not understand the need for this type of specialist, may be resistant to accepting their diagnosis, or may face challenges with juggling additional appointments. When researchers studied patients with stage 4 or 5 CKD — the stages at which the Organ Procurement and Transplant Network recommends that referrals should take place — they found that one in three patients wasn’t even seeing a nephrologist.⁷

It is worth noting that referral rates tend to be even lower among patients of color and patients of lower socioeconomic status. Though ESRD occurs four times more often in Black Americans than it does in their white counterparts, Black people are significantly less likely to be referred for a kidney transplant.^8,9

If that referral does happen — for any patient — the next challenge becomes matching with a living donor. Experts agree that educating patients on how to conduct a conversation with loved ones about kidney disease and the transplant process can be helpful, but not everyone receives such education. That lack of support can make the already daunting and high-stakes task of initiating such conversations that much more stressful.

Unfortunately, insufficient support can also plague the pre-transplant evaluation process. This lengthy process can stretch between one and six months, as it spans financial, psychological and health components.¹⁰ For patients and donors who must clear those hurdles on their own, the process can take an incredible amount of stamina and patience. But even then, such patients may miss the mark on timing. That’s because all evaluation hurdles must be cleared eight weeks before the transplant surgery, but the window between when dialysis is not yet needed and when it becomes necessary can be incredibly brief.

Zeroing in on smart solutions

We know that it’s possible to reach preemptive transplant rates higher than 2.5%, because research shows it. In one study, 13% of patients taking part in a care management program underwent transplants — besting the national average by more than a factor of five.¹¹

Specialized support may make all the difference. When a care coordinator is trained on the finer details of renal disease, they understand how swiftly it can swing from one stage to the next and the many ways to proactively slow the progression of the disease.

At the same time, comprehensive programs train such coordinators on the highly complex path toward kidney transplantation and are poised and equipped to support patients along this journey. That can mean patients are referred to transplant clinics earlier, potentially reducing health inequities present in kidney care, they are better educated on how to talk with loved ones about the disease, and they feelowered around and guided through the evaluation process. In short, more support and more connected care helps drive more preemptive kidney transplants.

As payers are stepping up with innovative programs for patients, health experts and researchers are rallying for systemic changes that can also turn the tide toward more preemptive transplants.

Earlier this year, the National Academies of Sciences, Engineering, and Medicine published Realizing the Promise of Equity in the Organ Transplantation System, a detailed report on the myriad improvements needed to get more lifesaving organs to waiting patients.¹² Part of the report’s recommendations centered on the need to increase total donor acceptance. These efforts would almost certainly involve a streamlining of the donor approval process, reducing friction and paving the way for more donors to be accepted and organs to be procured. The report challenged the Department of Health and Human Services to transplant 50,000 organs annually by 2026 and reduce rates of unused donated kidneys from the present 20% to 5% or less.¹³ It also urged health care providers across the country to adhere to standardized protocols for patient referral, in hopes of eliminating the bias that has kept some communities from having equal access to kidney transplants.

Taken together, these fresh approaches have the potential to transform the way in which kidney transplantation functions in the U.S. Such a shift would provide a profound benefit for patients and health plans alike and would represent a major achievement for the medical community at large.

Sources

1. • National Research Council. Realizing the Promise of Equity in the Organ Transplantation System. Washington, DC: The National Academies Press; 2022.
   • National Kidney Foundation. Preemptive transplant. National Kidney Foundation, kidney.org. Accessed September 20, 2022.
   • Optum. System-wide look at improving specialty care. Optum, optum.com. Accessed September 20, 2022.
   • Optum. Kidney Solutions: Preemptive transplants rates and cost savings. Optum, optum.com. Accessed September 20, 2022.
   • National Kidney Foundation. Preemptive kidney transplants: Why aren’t they more popular? National Kidney Foundation, kidney.org. Accessed September 20, 2022.
   • Fishbane S, Nair V. Opportunities for increasing the rate of preemptive kidney transplantation. Clinical Journal of the American Society of Nephrology: CJASN. 2018; 13(8).
   • Dharod A, et al. Primary care referrals to nephrology in patients with advanced kidney disease. American Journal of Managed Care. 2020;26(11).
   • Norris, KC, et al. Hemodialysis disparities in African Americans: The deeply integrated concept of race in the social fabric of our society. Seminars in dialysis. 2017;30(3).
   • Boulware LE, Purnell TS, Mohottige D. Systemic kidney transplant inequities for black individuals: Examining the contribution of racialized kidney function estimating equations. JAMA Netw Open. 2021.
   • National Kidney Foundation. Evaluation for kidney transplant. National Kidney Foundation, kidney.org. Accessed September 20, 2022.
   • Fishbane S, et al. Augmented nurse care management in CKD stages 4 to 5: A randomized trial. American Journal of Kidney Diseases. 2017;70(4).
   • National Research Council. Realizing the Promise of Equity in the Organ Transplantation System.
   • Organ Procurement and Transplantation Network. Educational guidance on patient referral to kidney transplantation. Organ Procurement and Transplantation Network, optn.transplant.hrsa.gov. Accessed September 20, 2022.