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Voucher-Based Kidney Donation and Redemption for Future Transplant

Educational Objective
(1) To identify the extent to which the use of family vouchers for future kidney transplant will help to expand the living donor pool. (2) Are voucher redemptions capable of facilitating timely kidney allografts?
1 Credit CME
Key Points

Question  Does the use of family vouchers for future kidney transplant help to expand the living donor pool, and are voucher redemptions capable of facilitating timely kidney allografts?

Findings  In this cohort study of 250 family voucher–based kidney donations across 79 transplant centers in the US, the use of vouchers precipitated 573 downstream kidney transplants. Although the reasons were multifactorial, the waiting time until transplant among candidate recipients in this kidney exchange registry decreased by 3 months since the inception of family voucher–based donation.

Meaning  These findings suggest that the family voucher program facilitated living kidney donations that may not otherwise have occurred by overcoming chronological incompatibility between donor-recipient pairs.


Importance  Policy makers, transplant professionals, and patient organizations agree that there is a need to increase the number of kidney transplants by facilitating living donation. Vouchers for future transplant provide a means of overcoming the chronological incompatibility that occurs when the ideal time for living donation differs from the time at which the intended recipient actually needs a transplant. However, uncertainty remains regarding the actual change in the number of living kidney donors associated with voucher programs and the capability of voucher redemptions to produce timely transplants.

Objective  To examine the consequences of voucher-based kidney donation and the capability of voucher redemptions to provide timely kidney allografts.

Design, Setting, and Participants  This multicenter cohort study of 79 transplant centers across the US used data from the National Kidney Registry from January 1, 2014, to January 31, 2021, to identify all family vouchers and patterns in downstream kidney-paired donations. The analysis included living kidney donors and recipients participating in the National Kidney Registry family voucher program.

Exposures  A voucher was provided to the intended recipient at the time of donation. Vouchers had no cash value and could not be sold, bartered, or transferred to another person. When a voucher was redeemed, a living donation chain was used to return a kidney to the voucher holder.

Main Outcomes and Measures  Deidentified demographic and clinical data from each kidney donation were evaluated, including the downstream patterns in kidney-paired donation. Voucher redemptions were separately evaluated and analyzed.

Results  Between 2014 and 2021, 250 family voucher–based donations were facilitated. Each donation precipitated a transplant chain with a mean (SD) length of 2.3 (1.6) downstream kidney transplants, facilitating 573 total transplants. Of those, 111 transplants (19.4%) were performed in highly sensitized recipients. Among 250 voucher donors, the median age was 46 years (range, 19-78 years), and 157 donors (62.8%) were female, 241 (96.4%) were White, and 104 (41.6%) had blood type O. Over a 7-year period, the waiting time for those in the National Kidney Registry exchange pool decreased by more than 3 months. Six vouchers were redeemed, and 3 of those redemptions were among individuals with blood type O. The time from voucher redemption to kidney transplant ranged from 36 to 155 days.

Conclusions and Relevance  In this study, the family voucher program appeared to mitigate a major disincentive to living kidney donation, namely the reluctance to donate a kidney in the present that could be redeemed in the future if needed. The program facilitated kidney donations that may not otherwise have occurred. All 6 of the redeemed vouchers produced timely kidney transplants, indicating the capability of the voucher program.

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Article Information

Accepted for Publication: March 20, 2021.

Published Online: June 23, 2021. doi:10.1001/jamasurg.2021.2375

Corresponding Author: Jeffrey L. Veale, MD, Kidney Transplant Exchange Program, UCLA Health, Department of Urology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, 200 Medical Plaza Dr, Ste 140, Los Angeles, CA 90095 (jveale@mednet.ucla.edu).

Author Contributions: Drs Nassiri and Veale had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Veale, Nassiri, Capron, Danovitch, Cooper, Kapur.

Acquisition, analysis, or interpretation of data: Veale, Nassiri, Gritsch, Cooper, Redfield, Kennealey.

Drafting of the manuscript: Veale, Nassiri, Capron, Cooper, Kennealey.

Critical revision of the manuscript for important intellectual content: Veale, Nassiri, Danovitch, Gritsch, Cooper, Redfield, Kennealey, Kapur.

Statistical analysis: Nassiri.

Administrative, technical, or material support: Nassiri, Gritsch, Cooper, Redfield, Kapur.

Supervision: Veale, Nassiri, Capron, Danovitch, Cooper.

Conflict of Interest Disclosures: Drs Veale, Cooper, Redfield, Kennealey, and Kapur reported serving as members of the medical board of the National Kidney Registry during the conduct of the study.

Veale  JL , Capron  AM , Nassiri  N ,  et al.  Vouchers for future kidney transplants to overcome “chronological incompatibility” between living donors and recipients.   Transplantation. 2017;101(9):2115-2119. doi:10.1097/TP.0000000000001744 PubMedGoogle ScholarCrossref
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LaPointe Rudow  D , Hays  R , Baliga  P ,  et al.  Consensus conference on best practices in live kidney donation: recommendations to optimize education, access, and care.   Am J Transplant. 2015;15(4):914-922. doi:10.1111/ajt.13173 PubMedGoogle ScholarCrossref
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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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