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