How might technology increase kidney transplant rates?

Chronic kidney disease (CKD) affects nearly 15% of the United States adult population and is the 9th leading cause of death. End stage renal disease (ESRD) is the most advanced form of CKD, where one’s kidneys no longer function appropriately and must be replaced via kidney transplant to continue living[1].

Brief background on kidney transplants

To get a sense for scope, nearly 100,000 patients are on the kidney transplant waitlist, but only about 20,000 transplants are performed each year. Even further (and sadly), it is estimated that 5,000 people on the waitlist die each year without getting a transplant[2]. Without getting too far in the weeds, the Center for Medicare & Medicaid (CMS) has designed 58 Organ Procurement Organizations (OPOs) that manage organ procurement, recovery, and allocation to transplant centers within designated geographies. There are nearly 300 transplant centers nationwide and they decide which patients are accepted onto their transplantation list. Accepted patients are registered in a national, computerized list, centrally managed by the Organ Procurement and Transplantation Network.

There is a clear imbalance between kidney transplant supply and demand. In a typical market, these imbalances are addressed via prices. Price goes up when demand is greater than supply, thereby reducing demand, but incentivizing the creation of more supply. However, the National Organ Transplant Act forbids waitlist patients from purchase organs and prohibits donors from receiving financial compensation. Thus, transplants ultimately remain constrained to the supply of donated kidneys.

The potential for technology

Nevertheless, with the context and economics of the “market” in mind, the rest of this blog will explore a few technology-driven solutions aiming address two of the biggest challenges associated with kidney transplants.

· How do we increase the supply of kidneys?

· How do we address the health inequities in the kidney transplant system?

Before diving in, one disclaimer is that this is a highly regulated and (like the rest of healthcare) complicated space. I will do my best to present ideas that that can fit within the current system (except for maybe one 😊), but admittedly I am still learning the nuances of how it all works.

For increasing kidney supply:

Donor evaluation as-a-service platform[3]. Today, the responsibility of evaluating kidney donors falls upon the transplant centers. The process involves a comprehensive medical evaluation, queries into genetic/familial disease, various diagnostic tests, etc. In short, it is a cumbersome process that requires significant clinical resources as well as tight coordination and engagement with the living donor. ‘Donor evaluation as-a-service’ would involve taking a digital-first approach and allowing transplant centers to essentially outsource the entire evaluation process. It would be the platform upon which donors connect with a “donor navigator”, book the necessary diagnostic testing, upload medical history, etc. In theory, delivering a more seamless, easier experience for living donors to donate their kidneys could increase kidney supply (i.e., less dropouts, more volunteers, etc.).

Gig platform for living donor needs: Another reason we lack adequate supply of living donors is because donors are not properly compensated for the both the financial and opportunity cost they incur when going through the donor process. For example, donors can (sometimes) be reimbursed for travel, but other expenses like lost wages and child/elder care are not reimbursed. A “crowdfunding” platform for living donors to cover travel and lost wages seems logical but is far too unrealistic. However, a Task Rabbit-type of marketplace platform where living donors can find volunteers willing to help them out with various tasks such as cooking meals, watching a child or elder, etc. could address some of the financial disincentives and reduce some of the friction faced when becoming a donor.

For addressing health inequities:

Purpose-built population health capabilities for transplant centers[4]: Among the near 100,000 patients waiting for kidney transplants, roughly 43% have ‘inactive’ status, meaning they will not appear on the match list. Patients can become inactive for various reasons such as medical illness and psychosocial barriers. Exploring inactivation criteria is outside the scope of this blog, but improving ‘reactivation’ (I made that term up) could help improve transplant rates among the underserved. One study found black and Hispanic patients were 19% and 27% (respectively) less likely to convert to back to active status than their white counterpart while another study determined frequent programmatic review allowed 18% of inactive patients to be made active. A population health management product built to serve the unique needs of a transplant center (e.g., capturing the data needed to make the active/inactive determination) could bundle this programmatic review with patient outreach and make the process more scalable. It seems feasible (and impactful) to build software that more easily allows transplant centers to better understand the current state of their inactive patients and subsequently engage with them to determine if re-activation is appropriate.

Because this article wouldn’t be complete without a crypto idea:

Kidney transplant decentralized autonomous organization (DAO): It seems unlikely that something like this would ever be legal (let alone viable), but here goes nothing. Those in need of a kidney could join the DAO by contributing a certain (capped) amount of money. This pool of money would be used to finance procedures (i.e., what isn’t covered by insurance) as well as reimburse living donors for various expenses. The pool of money could be re-invested in other liquid assets when it is sitting idle so it can generate a return. Whenever a kidney becomes available, members would then vote (they can’t vote for themselves) for which member of the DAO should be the one who receives it . The DAO itself could also be the overarching organization responsible for making sure members aren’t unnecessarily inactive, helping find new living donors, etc.

Closing thoughts

In general, I tried coming up with solutions that could (in theory) be built and could help address some of the biggest issues associated with kidney transplants. Unfortunately (and unsurprisingly?), I am not sure the financial incentives are in place to turn these ideas into viable, sustainable business models. Maybe one day a public/private partnership will form with the imperative to invest in new solutions that help move the needle in some capacity, and if it does, I think these are interesting places to start.

#CBSDigitalLiteracy

[1] https://trumpwhitehouse.archives.gov/wp-content/uploads/2021/01/CEA-Kidney-Transplant-Report1.8.211.pdf

[2] https://www.pennmedicine.org/news/news-releases/2020/december/too-many-donor-kidneys-are-discarded-in-us-before-transplantation#:~:text=The%20shortage%20of%20kidneys%20for,die%20without%20getting%20a%20transplant

[3] https://www.ajkd.org/article/S0272-6386(17)31078-8/fulltext#:~:text=Mandated%20laboratory%20testing%20for%20living,a%2024%2Dhour%20urine%20collection.

[4] https://www.ajkd.org/article/S0272-6386(21)00628-4/fulltext