Kidney transplantation remains the preferred renal replacement therapy for eligible patients with end-stage kidney disease (ESKD), offering improved survival and quality of life compared to long-term dialysis. However, the number of transplant candidates exceeds the number of available donor kidneys, and not all patients who desire a kidney transplant are eligible to receive one. As a result, all patients must undergo a thorough clinical evaluation to assess their transplant readiness, requiring complex care coordination between the patient, their providers, and the transplant center. This overview outlines the key steps for clinicians:

1. Evaluation
2. Listing 
3. Candidacy optimization
4. Living vs. deceased donation pathways
5. Care coordination responsibilities pre- and post-transplant

It is imperative for health plans and providers to understand and address the disparities among CKD patients in order to deliver quality, equitable care to all. By taking steps to advance health equity in kidney care, healthcare organizations can make a positive difference in their patients’ outcomes.

1) Multidisciplinary Evaluation: Medical, Psychosocial, and Financial

Medical assessment. Comprehensive evaluation includes cardiovascular risk stratification (echocardiography, stress testing, vascular imaging), infectious disease screening (hepatitis B/C, HIV, tuberculosis), malignancy screening, and assessment of frailty, nutritional status, and functional reserve. Immunologic workup (blood type, HLA typing, panel reactive antibody) informs compatibility and allocation priority.

Reference: National Kidney Foundation, “Evaluation for Kidney Transplant” [https://www.kidney.org/atoz/content/transplant-evaluation]

Psychosocial assessment. Behavioral health, treatment adherence history, substance use, cognitive function, and availability of a post-transplant caregiver are assessed. Psychosocial readiness predicts adherence to immunosuppressive regimens and follow-up requirements, and early identification of barriers allows for targeted interventions (social work, counseling, transportation assistance).

Financial assessment. Transplant centers review insurance coverage for surgery, hospitalization, and long-term immunosuppressive therapy. Since 2023, Medicare offers a Part B Immunosuppressive Drug (Part B-ID) benefit for eligible kidney transplant recipients without other coverage, reducing risk of post-transplant medication nonadherence due to cost.

2) Listing and Allocation

Referral to a transplant center should occur when the patient reaches stage 4 CKD, meaning their estimated glomerular filtration rate (eGFR) has fallen below 30 mL/min/1.73m², or earlier if progressive decline is anticipated. Following successful evaluation and committee approval, the patient is listed with the Organ Procurement and Transplantation Network (OPTN) once eGFR falls below 20 mL/min/1.73m².

• Waiting time accrues from dialysis initiation or from listing with qualifying eGFR/creatinine clearance documentation.
• Multiple listings at geographically distinct centers are permitted and may reduce wait time, though logistical demands must be considered.
• Allocation of deceased-donor kidneys is governed by OPTN policy, using factors such as blood type, HLA match, calculated panel reactive antibody (cPRA), and waiting time.

Reference: UNOS/OPTN, “How the Kidney Transplant Waiting List Works” [https://unos.org/transplant/waitlist/]

3) Optimizing Candidacy Prior to Listing and While Waiting

Clinical teams can improve transplant eligibility and post-transplant outcomes by:

• Controlling comorbidities: Optimize blood pressure, glycemic control, lipid profile, anemia, and mineral-bone disease.
• Cardiovascular clearance: Identify and address ischemic heart disease, heart failure, and peripheral vascular disease to reduce perioperative risk.
• Reducing modifiable surgical risk: Facilitate smoking cessation, weight management (target BMI thresholds per center policy), and dental clearance.
• Vaccinations: Complete recommended immunizations before transplantation as live vaccines are contraindicated post-transplant.
• Promoting adherence: Document medication and dialysis adherence and ensure consistent follow-up attendance.
• Establishing caregiver plans: Confirm availability of support for the intensive early post-transplant period.

4) Living vs. Deceased Donation

Living donor transplantation offers shorter time to transplant and superior graft longevity. Potential donors undergo extensive medical and psychosocial evaluation to protect their health. Kidney Paired Donation (KPD) networks expand access for incompatible pairs and should be discussed early in counseling.

Deceased donor transplantation remains the predominant pathway; candidates must be ready to respond quickly when an organ offer arises. Maintaining up-to-date contact information and ongoing clinical monitoring is essential.

Reference: OPTN, “Living Donation” [https://optn.transplant.hrsa.gov/patients/about-donation/living-donation]

Provider Role: While allocation decisions are made by transplant centers, referring providers play a key role in preparing patients for either living or deceased donation. Clinicians are responsible for presenting both pathways early and equitably, counseling patients on their relative benefits and considerations, and facilitating referral of interested living donor candidates to the transplant center’s independent donor evaluation team. 

Providers should also maintain close coordination with the transplant team to ensure patients remain ready, medically and psychosocially, for listing and transplantation.

5) Care Coordination Responsibilities

Pre-transplant: Nephrologists and population health teams can accelerate readiness by closing care gaps (cardiac workup, malignancy screening, vaccinations), supporting adherence, facilitating insurance approvals, and coordinating education on transplant risks and benefits.

Post-transplant: Coordination shifts to long-term management of immunosuppression, infection prophylaxis, cancer screening, and comorbidity control. Structured transitions of care from transplant center to primary care and nephrology are critical to prevent lapses in medication, monitoring, and follow-up.

Healthmap’s Role

Healthmap Solutions’ Kidney Population Health Management program supports this continuum by working directly with nephrologists, primary care physicians, transplant centers, and all other providers on a patient’s care team to coordinate pre- and post-transplant care. Our Care Navigation team assists with adherence support, testing reminders, medication management, and patient education to improve clinical outcomes. They also assist patients with overcoming barriers that may preclude them from engaging in the transplant evaluation process. By providing the support that patients and providers need, Healthmap effectively optimizes care for program members, leading to improved outcomes and lower cost of care for patients.