Managing the Costs of Kidney Paired Donation: A Survey of Contemporary U.S. Practice and Challenges

Kidney paired donation (KPD) is increasingly used to provide access to living donor kidney transplantation (LDKT), but concerns related to managing costs may pose barriers to transplant center participation. To help inform discussions of effective cost-management strategies, we surveyed U.S. LDKT program staff on experiences, practices, and needs for managing KPD-related costs.

A survey instrument was designed by a multidisciplinary workgroup of professionals in transplant administration, finance, and clinical practice. We distributed the survey to staff at U.S. LDKT transplant programs by email and posting to professional society listservs in 2024 using the Qualtrics platform.

Among 97 unique programs that responded, 88% report KPD participation, with 33% reporting >10 exchanges per year. Use of external exchanges among participating centers included the National Kidney Registry in 69%, Alliance for Paired Donation in 31%, and OPTN/UNOS in 31%. Reported resources for KPD include nurse coordinators (93%), physican champions (64%), financial expertise (47%), and contracting assistance (45%). Heterogeneous methods were used to cover registry fees and other costs, including evaluation, nephrectomy, and organ shipping. Although many centers rely on Medicare Cost Report (MCR) reimbursement or recipient insurance to manage expenses, more than one-quarter reported no formal cost-handling policies. Twenty-five percent of centers reported being uncomfortable discussing KPD costs with hospital administrators.

Based on a survey of U.S. LDKT programs, a variety of approaches are used to cover the costs of KPD practice. Findings also underscore gaps in financial infrastructure, including limited formal volume analyses to guide investment in KPD resources.