transplant champion handbook · benefit of kidney transplantation. jama 2005;294:2726-33 83: 1073 4...
TRANSCRIPT
Transplant Champion Handbook
Transplant Coordination: What You Need to Know
Table of Contents
Project Goals…………………………………………………………………..…..4
What is a Transplant Champion?............................................4
What is Patient Engagement?.................................................4
The Kidney Allocation System……………………………………..……...5
Multiple Listing………………………………………………………………..….7
Organ Procurement Organizations………………………………..…....8
UAB Transplant Selection Criteria………………………………………..9
UMMC Transplant Selection Criteria………………………………….11
Centennial Transplant Selection Criteria…….………………….….13
Erlanger Transplant Selection Criteria………………………………..15
Methodist Transplant Selection Criteria…………………………….18
Saint Thomas Transplant Selection Criteria………………………..20
UT Transplant Selection Criteria………………………………………..22
Vanderbilt Transplant Selection Criteria………………………….…24
Health Literacy…………………………………………………………………..26
Transplant Facility Contact Information…………………………….28
Project Goals The benefits of transplantation extend to ESRD patients regardless of age, gender, or ethnicity, as well as those with common comorbid conditions, including diabetes and hypertension1. Now that new donor rules give patients waiting list credit for all of their time on dialysis, all patients have more reasons than ever to consider this option.
This project is designed to increase transplantation by promoting the modality to all qualified candidates. The intent is to promote early referral to transplant, and assist patients and providers to improve referral patterns.
What is a Transplant Champion? A Transplant Champion is a dialysis facility staff member who is willing to speak to patients about the benefits of transplantation, by assessing the patient’s level of understanding and educating them based on their level of health literacy. A Transplant Champion can be a social worker, nurse, dietitian, or patient care technician.
What is Patient Engagement? Patient engagement is the active involvement of
patients and their families in their care and decision
making about treatment. It entails the patient having a
role and asking questions. Throughout the project,
facilities will be asked to incorporate peer to peer patient
education and involve patients and their support team in
making treatment option decisions.
1 Merion RM, Ashby VB, Wolfe RA, et al. Deceased-donor characteristics and the survival benefit of kidney transplantation. JAMA 2005;294:2726-33
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The Kidney Allocation System (KAS)
In 2014, a new kidney allocation system took effect that should help shorten the waiting time for a transplant, as well as help patients have longer function with their transplanted kidneys while best matching donor kidneys to recipients using specific classifications.
How are the kidneys classified?
Under the new system, each kidney that is offered for transplant has a Kidney Donor Profile Index (KDPI) score. This score is calculated based on facts about the donor that affect how long the kidney will likely function. The factors include:
Age Height Weight Ethnicity Whether the donor died
due to loss of heart function or loss of brain function
How are the transplant candidates classified?
Each patient who is a candidate for kidney transplant will get an individual Estimated Post-Transplant Survival (EPTS) score. This score is associated with how long a patient will need a functioning kidney when compared to other candidates. The EPTS is calculated based on facts about the patient that affect how long the person is likely to need a kidney. These factors include:
Age Length of time spent
on dialysis
Having received a previous transplant (of any organ)
Current diagnosis of diabetes
Stroke as cause of death History of high blood
pressure History of diabetes Exposure to the
hepatitis C virus Serum creatinine
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How are KDPI and EPTS scores used in allocating kidneys?
Donor kidneys that have a score of 20 percent or less (kidneys that are expected to last the longest) will be matched with patients who have an EPTS score of 20 percent or less. In the event that a kidney with a KDPI of 20 percent or less is not accepted for any of those patients, it will be offered to another patient who would match, regardless of their EPTS score.
Kidneys with high KDPI scores are not expected to function as long as others with lower scores and may best be used to help patients who are not able to stay on dialysis for a long time.
This information was obtained from the United Network for Organ Sharing booklet Questions and Answers for Transplant Candidates about Kidney Allocation. To read the entire booklet, please visit www.unos.org.
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Multiple Listing
According to Organ Procurement and Transplantation Network (OPTN) and United Network for Organ Sharing (UNOS) policy, patients may be listed at two or more transplant centers. Being listed at multiple transplant centers could reduce the waiting time for a transplant by several months, although it does not guarantee a shorter waiting time. Not all transplant programs accept multiple-listed patients, and others may set their own requirements for patients who are multiple-listed. There are 11 different regions that are used for U.S. organ allocation. Most patients would not benefit from listing at multiple transplant centers within the same allocation area, as priority is calculated among candidates at all hospitals within a local donation area—not for each individual hospital.
UNOS-OPTN Region Map
This information was obtained from www.unos.org.
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Organ Procurement Organizations (OPOs)
There are 58 different Organ Procurement Organizations in the United States, and they are responsible for two main functions: increasing the number of registered donors, and coordinating the donation process when donors become available.
When a donor becomes available, the OPOs evaluate the potential donors, check the deceased’s state’s donor registry, discuss donation with family members, contact the OPTN and run a match list. They also arrange for the recovery and transport of donated organs.
Here is a list of OPOs in Network 8:
ALABAMA Alabama Organ Center http://www.alabamaorgancenter.org/
MISSISSIPPI Mississippi Organ Recovery Agency http://www.msora.org/
Mid-South Transplant Foundation, Inc. (Northern Mississippi) http://midsouthtransplant.org/
TENNESSEE Mid-South Transplant Foundation, Inc. (Western Tennessee) http://midsouthtransplant.org/
Tennessee Donor Services (Central, Eastern Tennessee) https://www.donatelifetn.org/
8 This information was obtained from www.organdonor.gov.
Kidney Transplant Selection Criteria Inclusion Criteria
Chronic progressive disease with estimated glomerular filtration rate <30 mL/minute (early stage IV or V Chronic Kidney Disease)
Absolute Contraindications for Transplant Candidacy History of cancer treated within the 2 years prior to
evaluation, except basal and squamous cell skin cancers and certain kidney cancers
History of having a certain type of surgery to improve circulation to the legs, called aortobifemoral bypass grafting
Active alcohol or drug abuse, except tobacco
Severe heart disease with heart failure (Ejection fraction less than 20% by echocardiogram)
Important lung disease with severe breathing difficulty based on breathing tests and on home oxygen therapy
Active untreated infections (e.g. tuberculosis, fungal infections)
Morbid obesity with BMI > 40
Dependence on nursing home or other long-term care provider
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Relative Contraindications for Transplant Candidacy
Severe heart disease that would make surgery high risk
Severe peripheral vascular disease (poor circulation)
Active chronic liver disease in patients who are not candidates for combined liver/kidney transplant
Significant history of noncompliance with medical therapy
Obesity with BMI > 36
Certain kidney diseases, including oxalosis and sickle cell anemia
Active systemic illness requiring steroid therapy, such as lupus
Age > 70 years, depending on the overall health status of the patient
Significant dementia, or other disorder affecting mental status, without reliable caregiver
Financial hardship that would make it extremely difficult to receive the necessary post-transplant care
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UAB continued...
Kidney Transplant Selection Criteria Inclusion Criteria
Irreversible renal failure defined as Glomerular Filtration Rate (GFR), less than or equal to 20mL/minute
Patient currently on chronic dialysis Absolute Contraindications for Transplant Candidacy
Most malignancies within 2 years of treatment [with a few exceptions: nonmelanotic skin malignancies, incidental (< 5 cm in size, no clinical symptoms and discovered by chance) renal cell incidental prostatic CA found at TURP with Gleason score < 4]
HIV positive Uncorrectable severe coronary or peripheral vascular
disease
Dilated cardiomyopathy with EF < 15%
No payer source. No Medicare Part D or acceptable drug coverage plan
Unacceptable plan for post-transplant care Uncontrolled active psychosis
Active illicit drug usage
BMI > 39 (Rare exceptions may be approved by the Committee for BMI > 39)
Diabetes with active cigarette use
Coronary artery disease with active cigarette use Severe pulmonary hypertension [RVSP > 45mmHg on
ECHO with evidence of cardiac dysfunction (i.e. abnormal right atrial/ventricular function, requirement of O2 therapy, limited exercise tolerance)]
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Uncontrolled diabetes mellitus (HgA1C 10 or above)
Unacceptable risk to obtain good organ survival as assessed by Transplant Selection Committee based on associated comorbid conditions
Relative Contraindications for Transplant Candidacy Illicit drug usage within the past 6 months
Active infection (exceptions may be made in select patients @ surgeon’s discretion, for example, patient’s with PRA’s > 40 who are responsive to antibiotic therapy)
Non-compliance with dialysis prescription, medicines, appointments
PTH > 1000 (Exceptions may be made in select pa-tients such as Pediatrics)
Advance cirrhosis or liver failure. Exceptions will be patients with cirrhosis who are being considered for simultaneous liver and kidney transplantation. Patients with early stage cirrhosis (i.e. MELD < 10) or portal hypertension in the absence of liver dysfunction will be considered after hepatology evaluation
BMI 35 and 39, documented strict compliance with diabetes control is required (HgA1C < 8)
Inability to maintain activities of daily living or need for chronic custodial care
Severe COPD (FEV1 < 1L). Patients with documented lung disease will be required to demonstrate compliance with smoking cessation.
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UMMC continued...
Kidney Transplant Selection Criteria
Inclusion Criteria
Diagnosis of End Stage Renal Disease or Chronic Kidney Disease (GFR < 20)
Absolute Contraindications for Transplant Candidacy
BMI > 40 Active infections including Hbsag
Non-correctable, severe coronary artery disease, severe PVD, CHF or cardiomyopathy
Oxygen dependency
Unstable/Active psychopathology Active alcohol or drug abuse (except marijuana)
Inadequate psychosocial support
Age > 75 with comorbidities that preclude transplant
Recurrent and persistent non-compliance with medications and dialysis treatments
Comorbidities that preclude transplant Relative contraindications that will be reviewed prior to initiation of work-up are at the discretion of the physicians BMI > 35
Age > 70
Compromised cardiac function/EF < 30%
Compromised pulmonary function
Inability to understand the disease process, medication regimen and follow-up after transplant
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Prior history of substance abuse
Prior history of noncompliance with medical regimen Untreated active or chronic infections
Prior/current history of malignancy Contraindications are carefully evaluated by the transplant team and if present, may result in a candidate not being accepted for transplant at Centennial Medical Center. Contraindications are transplant program specific. Candidates not accepted at Centennial Medical Center can be referred to another center for evaluation. When a patient is placed on the UNOS waiting list or selected to receive a transplant, the transplant coordinator will document the selection criteria used for the patient in the patient’s medical record prior to listing the patient in UNET.
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Centennial continued...
Kidney Transplant Selection Criteria Inclusion Criteria End Stage Renal Disease as defined by one of the
following: A creatinine clearance less than 20mL/min A creatinine clearance between 20-30 mL/min
with significant symptomatology Progressive renal dysfunction where a decline
in clearance is predictable (e.g. diabetic nephropathy)
Absolute Contraindications for Transplant Candidacy History of invasive malignancy (excluding in situ
lesions) treated within the 2 years prior to evaluation, except non-melanoma skin cancer and certain inci-dental renal cell carcinomas
Uncontrolled major psychiatric disorders such as schizophrenia, bipolar or major depression with psychosis
Inability to care for self after transplantation or without adequate support systems
Advanced, non-reconstructable vascular disease (i.e. uncorrectable coronary or peripheral vascular disease)
Disseminated systemic infection (i.e. HIV, current TB, active Hepatitis, Nocardia, or fungal infection)
Advanced liver disease Current nonreversible anticoagulant therapy Active renal disease with an unreasonably high
chance of recurrence until disease markers indicate quiescence
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Active alcohol or substance abuse, excluding tobacco Ischemic cardiomyopathy with ejection fraction
< 20% Pulmonary hypertension with pulmonary artery
systolic pressure > 80mm/Hg Pulmonary disease with FEVI < 1.0 and on home
supplemental oxygen therapy Body mass index > 39 Dependence on nursing home or other long-term
care provider Inability to complete the transplant evaluation Communication that the patient does not want to
pursue transplantation at this time Comorbid conditions that would preclude long term
organ survival Relative Contraindications for Transplant Candidacy Age > 70 years, with candidacy determined on an
individualized basis, based on the overall health status of the candidate
Age < 18
Severe chronic lung disease or uncompensated pulmonary dysfunction
Heart failure with left ventricular ejection fraction < 30%
Absence of financial resources to support transplant and/or post-transplant follow-up (i.e. medications, living expenses, transportation, and medical care)
Tobacco use in the setting of: Type I Diabetes Mellitus Coronary Artery Disease Peripheral Vascular Disease Chronic Lung Disease
Evidence of previous substance abuse abstinence less than 6 months 16
Erlanger continued...
Significant cognitive impairment or physical limitation without reliable caregiver
Resources deemed inadequate to support the necessary post-transplant care
Candidates that have a higher than acceptable surgical risk
Body mass index 35-39 if deemed a high surgical risk
Significant history of noncompliance
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Kidney Transplant Selection Criteria Inclusion Criteria
End Stage Renal Disease
Decline in creatinine clearance to less than 20 cc/minute or
Creatinine clearance between 20-30 with significant symptoms or
Progressive renal dysfunction where a decline in clearance is predictable (diabetic nephropathy or symptomatic nephropathy with suitable living donor available with one of the above)
Absolute Contraindications for Transplant Candidacy
Untreated malignancy
Advanced non-reconstructive vascular disease
Uncompensated pulmonary dysfunction Disseminated systemic infection (including AIDS,
current Tuberculosis, Aspergillosis)
Disabling uncorrectable autonomic neuropathies
Untreated or uncontrolled major psychiatric illness Relative Contraindications for Transplant Candidacy
Non-rehabilitated substance abuse, or other maladaptive behavior determined by treating physicians to pose risk for non-compliance
Recently resected or treated malignancy Myocardial infarction within past 6 months and/or
angina at rest
Age >/= 75
Uninsured or under-insured patients (will be handled on a case by case basis). Information on fundraising will be provided to patients as required
Pregnancy Active renal disease with unreasonably high chance of
recurrence (such as active lupus, until disease markers indicate quiescence)
Medical unsuitability due to cardiopulmonary debility or other confounding medical conditions as determined by treating physicians
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Kidney Transplant Selection Criteria Inclusion Criteria
Initiation of dialysis therapy or GFR or creatinine clearance of 20 ml/min or less (calculated or measured)
Age - Adults 18 years old and over Absolute Contraindications for Transplant Candidacy
Active malignancy Current infection and active retrovirus infection
Active or untreated substance abuse (random drug screen may be required)
Acute psychosis and untreated or unmanaged psychiatric disorder
Chronic open non-healing ulcer or wound
Obesity-BMI > 45 Oxalosis
Inadequate family/financial/social support
Significant noncompliance with current medical regimen
Active Hepatitis B infection Home Oxygen dependence
Note: The issue of compliance must be addressed by the nephrologists and dialysis unit before referral to the transplant center.
Relative Contraindications for Transplant Candidacy:
Severe cardiac disease not amendable to treatment
Severe peripheral vascular or cerebral vascular disease not amendable to treatment
Significant cognitive impairment
Obesity-that would preclude safe transplantation
Advanced Hepatic Disease (Active Hepatitis B/Hepatitis C with Cirrhosis—may require referral to GI for liver biopsy and follow up)
Severe COPD/pulmonary hypertension or other lung disease
Current substance abuse (random drug screens may be required)
Age > 75
Inadequate bladder/urinary conduit
Previous organ transplant (other than kidney)
Inability to perform activities of daily living Indicators of malnutrition or BMI < 18
Inability to tolerate or comply with post-transplant medical regimen
Current tobacco use Indications for Re-transplantation
Need for renal replacement due to previous transplant failure in the absence of contraindications, or eGFR or creatinine clearance ≤ 20 mL/min
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Kidney Transplant Selection Criteria Absolute Contraindications for Transplant Candidacy Uncorrectable heart disease
Significant CAD that cannot be corrected, and/or patient demonstrates active symptoms
Ejection fraction </= 30% Active Hepatitis B/Hepatitis C with Cirrhosis
Pancreas: Hepatitis C Active bacterial/viral infection HIV virus infection Open, chronic non-healing ulcers/wounds Peripheral Gangrene Active Lupus
Symptoms Complement levels dropping High dose steroids (Prednisone > 5 mg/day)
Malignancy *Noncompliance
Physician appointments Dialysis clinic visits Medications Unacceptable fluid weight gain between
scheduled dialysis treatments Severe peripheral arterial aortic iliac disease Acute psychosis or untreated mental illness *must be addressed by Nephrologist and dialysis unit before referral to the transplant center
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Relative Contraindications for Transplant Candidacy Center specific age criteria
Kidney: no age limit Pancreas: 18-50 years of age
Obesity: BMI > 36% Pancreas: BMI > 30%
Chronic active Hepatitis C with a viral load greater than, or equal to 200,000 and biopsy c/w chronic active hepatitis
Chemical dependency Alcohol Illegal or non-prescribed drugs Tobacco use
Inability to care for self with no social support system to assist with post-transplant responsibilities
Medication set up/administration Transportation to clinic visits Self-care issues (hygiene)
Severe peripheral arterial occlusive disease Severe chronic obstructive pulmonary disease Treated malignancy Any condition deemed by the transplant surgeon, that
risk of transplant is greater than benefit *Referring nephrologists will have an opportunity to be involved in discussion of referred patients during our weekly scheduled patient selection committee meetings.
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Kidney Transplant Selection Criteria Indications
ESRD as evidenced by measured (actual urinary collection) creatinine clearance level or 20ml/min or initiation of dialysis
Absolute Contraindications for Transplant Candidacy
Morbid obesity (BMI > 45)
Active systemic infection Active substance abuse
Significant psychiatric illness likely to interfere with compliance
Severe uncorrectable cardiac or peripheral vascular disease
Active malignancy, see AST recommendations for wait intervals
Oxalosis (usually requires liver/kidney transplant) Hepatitis B infection (detectable viral load)
Poor family/social support
Cirrhosis or Stage III fibrosis on biopsy
Noncompliance with current medical regimen Relative Contraindications Age > 75
Severe obesity (BMI > 40)
Inadequate bladder/urinary conduit
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Guidelines for Living Donor Evaluations Renal
If CrCl < 85cc/min or > 140 corrected for BSA offer formal renal function testing (DTPA-GFR); if still below exclude.
If proteinuria > 150mg/24 hour urine exclude. If close or concurrent UTI repeat—if still above exclude.
If hematuria present, repeat urinalysis with counsel regarding clean catch urine. If still present obtain straight catch urine. If still present exclude donor or obtain formal urologic consultation.
History of one kidney stone or kidney stone noted on CTA obtain metabolic workup for kidney stone formation
Familial history of PCKD — see PCKD protocol for workup of donor with familial history of PCKD
Anatomic Contraindications
Kidney anatomy not suitable for donation/transplant per CTA results due to multiple vessels etc. Per the discretion of the donor and/or recipient surgeon.
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Health Literacy: Using the Teach Back Method With Your Patients www.pfizerhealthliteracy.com
Patients don’t understand or forget at least 50% of what is discussed in a typical office visit. Confirm understanding through teach-back.
This involves asking the patient to repeat back their understanding of the information you have discussed. Teach-back can also be used to confirm that the patient can demonstrate a new skill. Teach-back takes about 1 minute, and it is one of the most important things you can do when counseling patients. There are a few key steps to performing an effective teach-back.
a. First, make it normal, so the patient does not feel singled out. Example: “I do this next part with all my patients.”
b. Second, put the burden on your shoulders. It’s your job to have explained things clearly. Example: “I want to be sure I explained things clearly today.”
c. Third, be specific about what you would like the patient to tell you. Example: “We talked about starting a new medicine today. Please tell me your understanding of why it’s important… Ok, now please tell me your understanding of how to take it.”
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d. Fourth, if the patient’s explanation is insufficient, put the burden on your shoulders, reteach the information, and reassess understanding. Example: “I must not have explained that very well. The new medicine is for… I’d like you to take it… Now, let’s see if I did a better job explaining it that time. Could you please tell me again what the new medicine is for, and how you should take it?”
e. Teach-back can also be used to assess a skill. Example: “Please show me how you would use this inhaler.”
Teach-back can be used when explaining the transplant evaluation process. Implement this technique to evaluate patient understanding of next steps for transplant evaluation.
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Transplant Facility Contact Information
ALABAMA:
UAB Medicine Transplant Institute Phone: (205) 975-9200 Toll Free: (888) 822-7892 Fax: (205) 975-9199 Website: https://www.uabmedicine.org MISSISSIPPI:
UMMC Kidney Transplant Phone: (601) 984-5065 Fax: (601) 984-2962 Website: https://www.umc.edu TENNESSEE:
Centennial Transplant Center Phone: (615) 342-5626 Toll Free: (800) 642-4012 Fax: (615) 342-5635 Website: https://tristarcentennial.com/
service/kidney-transplant UT - Erlanger Kidney Transplant Center Phone: (423) 778-8067 Fax: (423) 778-6674 Website: https://www.erlanger.org
Methodist University Hospital Transplant Phone: (901) 516-9183 Fax: (901) 516-2424 Website: http://www.methodisthealth.org St. Thomas Hospital Phone: (615) 222-6618 Fax: (615) 222-6074 Website: https://www.sthealth.com/medical-
services/kidney-transplant-program UT Medical Center Phone: (865) 305-9236 Fax: (865) 305-6117 Website: https://www.utmedicalcenter.org Vanderbilt Transplant Phone: (615) 936-0695 Fax: (615) 936-0697 Website: https://www.vanderbilthealth.com/
transplant/
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This material was prepared under CMS contract Number HHSN-500-
2016-NW00008C, and the contents may not reflect CMS Policy.
Network 8, Inc. 775 Woodlands Parkway, Suite 310
Ridgeland, MS 39157 Toll free: (877) 936-9260 Phone: (601) 936-9260