Description:
Kidney transplant, a treatment option for end-stage renal disease (ESRD), involves the surgical removal of a kidney from a cadaver, living-related donor, or living-unrelated donor and transplantation into the recipient.

For individuals who have ESRD without contraindications to kidney transplant who receive a kidney transplant from a living donor or deceased (cadaveric) donor, the evidence includes registry data and case series. Relevant outcomes are overall survival, morbid events, and treatment-related mortality and morbidity. Data from large registries have demonstrated reasonably high survival rates after kidney transplant for appropriately selected patients and significantly higher survival rates for patients undergoing kidney transplant compared with those who remained on a waiting list. Kidney transplantation is contraindicated for patients in whom the procedure is expected to be futile due to comorbid disease or in whom posttransplantation care is expected to significantly worsen comorbid conditions. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. 

For individuals who have a failed kidney transplant without contraindications to kidney transplant who receive a kidney retransplant from a living donor or deceased (cadaveric) donor, the evidence includes registry data and case series. Relevant outcomes are overall survival, morbid events, and treatment-related mortality and morbidity. Data have demonstrated reasonably high survival rates after kidney retransplant (e.g., 5-year survival rates ranging from 87% to 96%) for appropriately selected patients. Kidney retransplantation is contraindicated for patients in whom the procedure is expected to be futile due to comorbid disease or in whom posttransplantation care is expected to significantly worsen comorbid conditions. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Background 
Solid organ transplantation offers a treatment option for patients with different types of end-stage organ failure that can be lifesaving or provide significant improvements to a patient’s quality of life.¹ Many advances have been made in the last several decades to reduce perioperative complications. Available data supports improvement in long-term survival as well as improved quality of life particularly for liver, kidney, pancreas, heart, and lung transplants. Allograft rejection remains a key early and late complication risk for any organ transplantation. Transplant recipients require life-long immunosuppression to prevent rejection. Patients are prioritized for transplant by mortality risk and severity of illness criteria developed by Organ Procurement and Transplantation Network (OPTN) and United Network of Organ Sharing (UNOS).

Kidney Transplant
In 2019, 39719 transplants were performed in the United States procured from almost 11,900 deceased donors and 7,400 living donors.² Kidney transplants were the most common procedure with 23,401 transplants performed from both deceased and living donors in 2019. Since 1988, the cumulative number of kidney transplants is over 478,000.³ Of the cumulative total, 66.5% of the kidneys came from deceased donors and 33.5% from living donors.

Kidney transplant, using kidneys from deceased or living donors, is an accepted treatment of end-stage renal disease (ESRD). ESRD refers to the inability of the kidneys to perform their functions (i.e., filtering wastes and excess fluids from the blood). ESRD, which is life-threatening, is also known as chronic kidney disease stage 5 and is defined as a glomerular filtration rate (GFR) less than 15 mL/min/1.73 m².⁴ Patients with advanced chronic kidney disease, mainly stage 4 (GFR 15 to 29 mL/min/1.73 m²) and stage 5 (GFR < 15 mL/min/1.73 m²), should be evaluated for transplant.⁵ Being on dialysis is not a requirement to be considered for kidney transplant. Severe non-compliance and substance abuse serve as contraindications to kidney transplantation but even those could be overcome with clinician support and patient motivation. All kidney transplant candidates receive organ allocation points based on waiting time, age, donor-recipient immune system compatibility, prior living donor status, distance from donor hospital, and survival benefit.^6,7

Combined kidney and pancreas transplants and management of acute rejection of kidney transplant using either intravenous immunoglobulin or plasmapheresis are discussed in separate evidence reviews.

Regulatory Status
A kidney transplant is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.

The U.S. Food and Drug Administration regulates human cells and tissues intended for implantation, transplantation, or infusion through the Center for Biologics Evaluation and Research, under Code of Federal Regulation Title 21, parts 1270 and 1271. Kidney transplants are included in these regulations.

Related Policies
70302 Allogeneic Pancreas Transplant
80105 Immune Globulin Therapy
80202 Plasma Exchange

Policy:
Kidney transplants with either a living or cadaver donor may be considered MEDICALLY NECESSARY for carefully selected candidates with end-stage renal disease.

Kidney retransplant after a failed primary kidney transplant may be considered MEDICALLY NECESSARY in patients who meet criteria for kidney transplantation.

Kidney transplant is investigational and/or unproven and therefore NOT MEDICALLY NECESSARY in all other situations.

Policy Guidelines 
Contraindications
Potential contraindications to solid organ transplant (subject to the judgment of the transplant center):

1. Known current malignancy, including metastatic cancer
2. Recent malignancy with high risk of recurrence
3. History of cancer with a moderate risk of recurrence
4. Systemic disease that could be exacerbated by immunosuppression
5. Untreated systemic infection making immunosuppression unsafe, including chronic infection
6. Other irreversible end-stage disease not attributed to kidney disease
7. Psychosocial conditions or chemical dependency affecting ability to adhere to therapy

Renal-Specific Criteria 
Indications for renal transplant include a creatinine level of greater than 8 mg/dL, or greater than 6 mg/dL in symptomatic diabetic patients; however, consideration for listing for renal transplant may start well before the creatinine level reaches this point, based on the anticipated time that a patient may spend on the waiting list.

CODING
See the Codes table for details.

Benefit Application
BlueCard/National Account Issues
Transplants, such as a kidney transplant, should be considered for coverage under the transplant benefit and should be evaluated for charge in accordance with traditional transplant benefits.

Which expenses are incurred during the evaluation and procurement of organs and tissues should be compared with the scope of human organ transplant benefits for coverage determination. Typically, the following are considered human organ transplant benefits:

• Hospitalization of the recipient and living donor for medically recognized transplants from a donor to a transplant recipient
• Evaluation tests requiring hospitalization to determine the suitability of both potential and actual donors, when such tests cannot be safely and effectively performed on an outpatient basis
• Hospital room, board, and general nursing in semi-private rooms
• Special care units, such as coronary and intentive care
• Hospital ancillary services
• Physicians’ services for surgery, technical assistance, administration of anesthetics, and medical care
• Acquisition, preparation, transportation, and storage of organ
• Diagnostic services
• Drugs that require a prescription by federal law

Expenses incurred in the evaluation and procurement of organs and tissues are considered benefits when billed by the hospital. Included in these expenses may be specific charges for participation with registries for organ procurement, operating rooms, supplies, use of hospital equipment and transportation of the tissue or organ to be evaluated.

Administration of products with a specific transplant benefit needs to be defined as to:

• When the benefit begins (at the time of admission for the transplant or once the patient is determined eligible for a transplant, which may include tests or office visits prior to transplant).
• When the benefit ends (at the time of discharge from the hospital or at the end of required follow-up, including the immunosuppressive drugs administered on an outpatient basis).

Coverage usually is not provided for:

• Human organ transplant services for which the cost is covered or funded by governmental, foundational, or charitable grants.
• Organs sold rather than donated to the recipient.
• An artificial organ.

Rationale
This evidence review was created.

This evidence review was created in December 1995 and has been updated regularly with searches of the PubMed database. The most recent literature update was performed through June 10, 2022.

Evidence reviews assess the clinical evidence to determine whether the use of technology improves the net health outcome. Broadly defined, health outcomes are the length of life, quality of life, and ability to function including benefits and harms. Every clinical condition has specific outcomes that are important to patients and managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of technology, 2 domains are examined: the relevance, and quality and credibility. To be relevant, studies must represent 1 or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. Randomized controlled trials are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

Kidney Transplant
Clinical Context and Therapy Purpose
The purpose of a kidney transplant in patients who have end-stage renal disease (ESRD) without contraindications to a kidney transplant is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does kidney transplantation improve the net health outcome in individuals with ESRD without contraindications to kidney transplant?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with ESRD without contraindications to a kidney transplant. ESRD refers to the inability of the kidneys to perform their functions (i.e., filtering wastes and excess fluids from the blood). ESRD, which is life-threatening, is also known as stage 5 chronic renal failure and is defined as a glomerular filtration rate less than 15 mL/min/1.73 m2.⁴

Interventions
The therapy being considered is kidney transplant from a living or cadaveric donor.

Comparators
The following therapies and practices are currently being used to make decisions about managing ESRD: medical management, including dialysis and medications to control symptoms. Dialysis is an artificial replacement for some kidney functions. Dialysis is used as a supportive measure in patients who do not want kidney transplants or who are not transplant candidates; it can also be used as a temporary measure in patients awaiting a kidney transplant.

Outcomes
The general outcomes of interest are overall survival (OS), elimination of the need for dialysis, and treatment-related adverse events (e.g., immunosuppression, graft failure, surgical complications, infections), with follow-up ranging from 30 days posttransplantation to up to 10 years or more. See the Potential Contraindications section for a detailed discussion.

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs.
• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
• Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Systematic Reviews
Chaudhry et al. (2022) published a systematic review that compared survival for waitlisted patients with kidney failure who received a transplant compared to those who remained on the transplant waitlist.8, A total of 48 observational studies were included in the systematic review, of which 18 studies were suitable for meta-analysis. Results demonstrated a 55% reduction in the risk of mortality in patients who received a transplant compared to those who remained on dialysis (hazard ratio [HR], 0.45; 95% confidence interval [CI], 0.39 to 0.54; p < .001).

Registry Studies
According to data analysis from the Organ Procurement and Transplantation Network (OPTN), between 2008 and 2015, the 1-year survival of patients undergoing an initial kidney transplant was 97.1% (95% CI, 96.9% to 97.2%).3, Five-year survival was 86.5% (95% CI, 86.2% to 86.8% ).

Krishnan et al. (2015) published a study of 17,681 patients in a U.K. transplant database who received a kidney transplant or were on a list to receive a kidney transplant.⁹ Authors found significantly higher 1- and 5-year survival rates in patients who underwent a kidney transplant than in those who remained on dialysis (exact survival rates not reported).

Transplants Stratified by Donor Source
The UNOS proposed an Expanded Criteria Donor (ECD) approach in 2002 to include brain-dead donors over 60 years or between 50 and 59 years old with 2 or more of the following criteria: serum creatinine level greater than 1.5 mg/dL, death caused by cerebrovascular accident, or history of high blood pressure.¹⁰

Querard et al. (2016) conducted a systematic review and meta-analysis of studies comparing survival outcomes with ECD versus Standard Criteria Donor (SCD) kidney transplant recipients.¹⁰ Reviewers identified 32 publications, 5 of which adjusted for potential confounding factors. A pooled analysis of 2 studies reporting higher rates of patient-graft failure for ECD kidney recipients found a significantly higher adjusted HR for patient-graft survival (HR, 1.68; 95% CI, 1.32 to 2.12). Meta-analyses were not conducted for patient survival outcomes; however, 1 study (N = 189) found a higher but nonsignificant difference in patient survival with ECD than with SCD (HR, 1.97; 95% CI, 0.99 to 3.91) and another study (N = 13833) found a significantly increased risk of death with ECD than with SCD (HR, 1.25; 95% CI, 1.12 to 1.40).

Pestana (2017) published a retrospective, single-center analysis of kidney transplants performed between 1998 and 2015 at a hospital in Brazil.¹¹ Of the 11,436 transplants analyzed, 31% (n = 3614) were performed under SCD, while 14% (n = 1618) were performed under ECD. The number of ECD recipients increased over time, from 29 transplants in 1998 to 2000 to 450 transplants from 2013 to 2014. Patient survival with ECD increased from 1998 to 2002 to 2011 to 2014 (from 79.7% to 89.2%, p < .001); a similar increase was noted in patient survival with SCD over the same time periods (from 73.1% to 85.2%, p < .001). The study was limited by reliance on limited registry data.

Several studies have reported long-term outcomes in live kidney donors. The most appropriate control group to evaluate whether donors have increased risks of morbidity and mortality are individuals who meet the criteria for kidney donation but who did not undergo the procedure. These types of studies have provided mixed findings. For example, Segev et al. (2010) found that donors had an increased mortality risk.¹² The authors analyzed data from a national registry of 80,347 live donors in the U.S. who donated organs between April 1994 and March 2009 and compared their data with data from 9364 participants of the National Health and Nutrition Examination Survey (excluding those with contraindications to kidney donation). There were 25 deaths within 90 days of live kidney donation during the study period. Surgical mortality from live kidney donors was 3.1 per 10,000 donors (95% CI, 2.0 to 4.6) and did not change over time, despite differences in practice and selection. Long-term risk of death was no higher for live donors than for age- and comorbidity-matched National Health and Nutrition Examination Survey III participants for all patients and also stratified by age, sex, and race.

Potential Contraindications to Kidney Transplant
Human Immunodeficiency Virus Infection
Patients infected with human immunodeficiency virus (HIV) may receive organs from HIV-positive donors under approved research protocols through the HIV Organ Policy Equity Act. As of November 2017, 6 hospitals performed 34 such transplants (23 kidney and 11 liver transplants), involving organs from 14 deceased donors. In a prospective, nonrandomized study, Muller et al. (2015) noted that HIV-positive patients transplanted with kidneys from donors testing positive for HIV showed a 5-year survival rate of 74%.¹³ Researchers noted that the HIV infection remained well-controlled and the virus was undetectable in the blood after transplantation.

Locke et al. (2015) examined outcomes in 499 HIV-positive kidney transplant recipients identified in the Scientific Registry of Transplant Recipients.¹⁴ Compared with early era transplants (2004 – 2007), patients transplanted more recently (2008 – 2011) had a significantly lower risk of death (HR, 0.59; 95% CI, 0.39 to 0.90). The 5-year patient survival rate was 78.2% for patients transplanted in the early era and 85.8% for more recent transplants. In another study, Locke et al. (2015) compared outcomes in 467 adult kidney transplant recipients with 4670 HIV-negative controls, matched on demographic characteristics.¹⁵ Compared with HIV-negative controls, survival among HIV-positive transplant recipients was similar at 5 years posttransplant (83.5% vs. 86.2%, p = .06). At 10 years, HIV-positive transplant recipients had a significantly lower survival rate (51.6%) than HIV-negative patients (72.1%; p < .001). The lower 10-year survival rate was likely due to HIV and hepatitis C virus (HCV) coinfection; survival rates at 10 years in HIV-monoinfected patients and HIV-negative patients were similar (88.7% vs. 89.1%, p = .50). Locke et al. (2017) found significantly lower 5-year mortality rates in HIV-infected patients with ESRD who had kidney transplants compared with continued dialysis (adjusted relative risk [RR], 0.21; 95% CI, 0.10 to 0.42; p < .001).¹⁶

In addition, Sawinski et al. (2015) analyzed survival outcomes in patients infected with HIV, HCV, or HIV plus HCV.¹⁷ The analysis included 492 HIV-infected patients, 5605 HCV-infected patients, 147 coinfected patients, and 117,791 noninfected patients. In a multivariate analysis, compared with noninfected patients, HIV-infected patients did not have an increased risk of death (HR, 0.90; 95% CI, 0.66 to 1.24). However, HCV infection (HR, 1.44; 95% CI, 1.33 to 1.56) and HIV and HCV coinfection (HR, 2.26; 95% CI, 1.45 to 3.52) were both significantly associated with an increased risk of death.

Zheng et al. (2019) performed a meta-analysis of 27 cohort studies, accounting for 1670 cases, to analyze various outcomes among HIV-positive patients who underwent kidney transplantation.¹⁸ The results revealed 97% (95% CI, 95% to 98%) survival at 1 year and 94% (95% CI, 90% to 97%) survival at 3 years. Other outcomes comprised 91% (95% CI, 88% to 94%) graft survival at 1 year, 81% (95% CI, 74% to 87%) graft survival at 3 years, 33% (95% CI, 28% to 38%) with acute rejections at 1 year, and 41% (95% CI, 34% to 50%) with infectious complications at 1 year.

Current OPTN policy permits HIV-positive transplant candidates.⁷

The British HIV Association and the British Transplantation Society (2017) updated their guidelines on kidney transplantation in patients with HIV disease.¹⁹ These criteria may be extrapolated to other organs:

Adherent with treatment, particularly antiretroviral therapy

Cluster of differentiation 4 count greater than 100 cells/mL (ideally > 200 cells/mL) for at least 3 months

Undetectable HIV viremia (< 50 HIV-1 RNA copies/mL) for at least 6 months

No opportunistic infections for at least 6 months

No history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma.

Hepatitis C Infection
A meta-analysis by Fabrizi et al. (2014) identified 18 observational studies comparing kidney transplant outcomes in patients with and without hepatitis C virus (HCV) infection.²⁰ The studies included 133,350 transplant recipients. In an adjusted analysis, the risk of all-cause mortality was significantly higher in HCV-positive versus HCV-negative patients (RR, 1.85; 95% CI, 1.49 to 2.31). Risks were elevated in various study subgroups examined by investigators. When the analysis was limited to the 4 studies from the U.S., the adjusted RR was 1.29 (95% CI, 1.15 to 1.44). In an analysis of 10 studies published since 2000, the RR was 1.84 (95% CI, 1.45 to 2.34). An analysis of disease-specific mortality suggested that at least part of the increased risk in mortality among HCV-positive individuals must have been due to chronic liver disease. In a meta-analysis of 9 studies, the risk of liver disease-related mortality was considerably elevated in patients infected with HCV than in those uninfected (odds ratio, 11.6; 95% CI, 5.54 to 24.4).

In the analysis by Sawinski et al. (2015), described above, HCV infection was associated with an increased risk of mortality in kidney transplant patients compared with noninfected patients.¹⁷

Obesity
Several studies have found that obese kidney transplant patients have improved outcomes compared with patients on a waiting list matched by body mass index (BMI). Study results on whether morbid obesity is associated with an increased risk of adverse events after kidney transplant are conflicting.

In an analysis of kidney transplant data from the U.K., Krishnan et al. (2015) reported on BMI data for 13,536 patients.⁹ They devised several BMI categories (i.e., < 18.5 kg/m2, 18.5 to < 25 kg/m2, 25 to < 30 kg/m2, 30 to < 35 kg/m2, and 35 to < 40 kg/m2). For each BMI category, patient survival was significantly higher in those who underwent kidney transplants compared with those who remained on a waiting list. In a similar analysis of U.S. data, Gil et al. (2013) noted that the risk of mortality at 1 year was significantly lower in patients who underwent transplantation than in those who remained on the waiting list for all BMI categories.²¹ For example, the risk was lower for patients with a BMI of at least 40 kg/m2 who received organs from donors who met standard criteria (HR, 0.52; 95 CI, 0.37 to 0.72) and for patients with BMI 35 to 39 kg/m2 who received organs from SCD donors (HR, 0.34; 95% CI, 0.26 to 0.46).

Pieloch et al. (2014) retrospectively reviewed data from the OPTN database.²² The sample included 6055 morbidly obese patients (ie, BMI, 35 to 40 kg/m2) and 24,077 normal-weight individuals who underwent kidney transplant between 2001 and 2006. After controlling for potentially confounding factors, the overall 3-year patient mortality did not differ significantly between obese and normal-weight patients (HR, 1.03; 95% CI, 0.96 to 1.12). Similar results were found for 3-year graft failure (HR, 1.04; 95% CI, 0.98 to 1.11). In subgroup analyses, obese patients who were non-dialysis-dependent, nondiabetic, younger, receiving living donor transplants, and needing no assistance with daily living activities had significantly lower 3-year mortality rates than normal-weight individuals. For example, the odds for mortality between nondiabetic obese and normal-weight patients was 0.53 (95% CI, 0.44 to 0.63).

A multivariate analysis of the effect of obesity on transplant outcomes by Kwan et al. (2016) included 191,091 patients from the Scientific Registry of Transplant Recipients database.²³ Covariates in the analysis included age, sex, graft type, ethnicity, diabetes, peripheral vascular disease, dialysis time, and time period of transplantation. Multivariate regression analysis indicated that obese patients had a significantly increased risk of adverse transplant outcomes including delayed graft function, urine protein, acute rejection, and graft failure (p < .001 for all outcomes). The risk of adverse outcomes of obesity increased with increasing BMI (e.g., see Table 1), and was independent of the effect of diabetes.

Table 1. Hazard Ratio of Graft Failure Relative to a Body Mass Index of 18.5 to 24.9 kg/m2

Body Mass Index, kg/m2	Hazard Ratio	95% Confidence Interval	p
25 to 29.9	1.015	0.983 to 1.047	.416
30 to 34.9	1.104	1.065 to 1.145	< .001
35 to 39.9	1.216	1.158 to 1.276	< .001
40+	1.248	1.156 to 1.348	< .001

Type 2 Diabetes
Kervinen et al. (2018) looked at the probability of receiving renal transplantation and survival after transplantation for patients with type 2 diabetes mellitus (T2DM).²⁴ Using the Finnish Registry for Kidney Diseases, which included 5419 patients between the years 2000 and 2010, 1065 individuals with T2DM were identified, of which 105 received a kidney transplant during follow-up. The relative probability of renal transplantation was 0.25 (95% CI, 0.20 to 0.30; p < .001) for T2DM patients compared with non-diabetic patients. Survival probabilities at 5 years after transplantation were 88% for T2DM and 93% for non-diabetic patients (adjusted HR for death 1.39, 95% CI, 0.82 to 2.35; p = .227). The limitations of this study were the relatively small number of T2DM patients receiving kidney transplantation and almost all of these were from deceased donors. Also, the transplantation criteria for T2DM patients in Finland may give better survival rates in the study.

Lim et al. (2017) evaluated all-cause mortality following kidney transplantation in patients with T2DM from the Australia and New Zealand Dialysis and Transplant Registry.²⁵ Of 10,714 transplant recipients during the study period, 985 (9%) had T2DM. The 10-year unadjusted OS in patients with an intact graft was 53% for individuals who had diabetes compared with 83% for transplant recipients who did not. The adjusted HR for all-cause mortality in patients with diabetes was 1.60 (95% CI, 1.37 to 1.86; p < .001), with the excess risk of death attributable to both cardiovascular disease and infection. Graft survival rates at 1, 5, and 10 years were 94%, 85%, and 70% in patients with diabetes compared with 95%, 89%, and 78% in transplant recipients without diabetes (p < .001), respectively.

Section Summary: Kidney Transplant
A large number of kidney transplants have been performed worldwide. Available data have demonstrated reasonably high survival rates after kidney transplant for appropriately selected patients and significantly higher survival rates for patients undergoing kidney transplant compared with those who remained on a waiting list. HIV infection has not been found to increase the risk of adverse events after kidney transplantation. Obesity and T2DM may increase the risk of adverse outcomes, and some data have suggested that kidney transplant recipients with HCV have worse outcomes than those without hepatitis C infection; however, data have not shown that patients with these conditions do not benefit from kidney transplants.

Kidney Retransplant
Clinical Context and Therapy Purpose
The purpose of kidney retransplants in patients who have a failed kidney transplant without contraindications to another kidney transplant is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The question addressed in this evidence review is: Does kidney retransplant improve net health outcomes in individuals with failed kidney transplants who do not have contraindications to another kidney transplant?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with a failed kidney transplant without contraindications to another kidney transplant.

Interventions
The therapy being considered is kidney retransplant from a living or cadaveric donor.

Comparators
The following therapies and practices are currently being used to make decisions about managing patients whose kidney transplant has failed: medical management including dialysis, self-care, and medications, including dietary supplements and diuretics.

Outcomes
The general outcomes of interest are OS, elimination of the need for dialysis, and treatment-related adverse events (e.g., immunosuppression, graft failure, surgical complications, infections), with follow-up ranging from immediate postsurgery to 30 days posttransplantation and long-term follow-up out to 10 years or more. See the Potential Contraindications section for a detailed discussion.

Study Selection Criteria
Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;
• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies;
• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought;
• Studies with duplicative or overlapping populations were excluded.

Review of Evidence
Case Series
Barocci et al. (2009) in Italy reported on long-term survival after kidney retransplantation.²⁶ There were 100 (0.8%) second transplants of 1302 kidney transplants performed at a single-center between 1983 and 2007. Among the second kidney recipients, 1-, 5-, and 10-year patient survival rates were 100%, 96%, and 92%, respectively. Graft survival rates at 1, 5, and 10 years were 85%, 72%, and 53%, respectively.

Registry Studies
Kainz et al. (2022) investigated the association of time on waitlist with survival in patients who received a second transplant versus those who remained on the waitlist.²⁷ A total of 2346 patients from the Austrian Dialysis and Transplant Registry and Eurotransplant were retrospectively analyzed. Results demonstrated that retransplantation improved survival at 10 years of follow-up compared with remaining on the waitlist (HR for mortality, 0.73; 95% CI, 0.53 to 0.95). For patients with a waitlist time for retransplantation of < 1 and 8 years after first graft loss, the mean survival time differences at 10 years were 8.0 life months gained (95% CI, 1.9 to 14.0) and 0.1 life months gained (95% CI, -14.3 to 15.2), respectively.

According to data analysis from the OPTN between 2008 and 2015, the 1-year survival rate of patients undergoing a repeat kidney transplant was 97.2% (95% CI, 96.8% to 97.5%).³ The 5-year patient survival rate after a repeat kidney transplant was 88.2% (95% CI, 87.4% to 88.9% ).

Children
Gupta et al. (2015) retrospectively analyzed OPTN data, focusing on patients who had an initial kidney transplant as children.²⁸ A total of 2,281 patients were identified who had their first transplant when they were younger than 18 years and a second kidney transplant at any age. In multivariate analysis, the length of first graft survival and age at second graft were significantly associated with second graft survival. Specifically, the first graft survival time of more than 5 years was associated with better second graft survival. However, patients who were between 15 and 20 years old at second transplant were at increased risk of second kidney graft failure compared with patients in other age groups.

Potential Contraindications to Kidney Retransplant
Human Immunodeficiency Virus Infection
Shelton et al. (2017) evaluated outcomes in HIV-infected patients undergoing kidney retransplantation.²⁹ In adjusted survival analysis, HIV-infected retransplant patients had a significantly increased risk of death compared with HIV-negative patients (HR, 3.11; 95% CI, 1.82 to 5.34). Other factors significantly associated with an increased risk of death after kidney retransplantation included recipient infection with HCV (HR, 1.77; 95% CI, 1.32 to 2.38) and grafts from older donors (HR, 1.01; 95 CI, 1.00 to 1.02). The analysis included only 22 HIV-infected patients, which is too small to draw conclusions about the appropriateness of kidney retransplantation in HIV-infected individuals.

Other contraindications are discussed in the section on initial kidney transplants.

Section Summary: Kidney Retransplant
Data have demonstrated reasonably high survival rates after kidney retransplants for appropriately selected patients (e.g., 5-year survival rates ranging from 87% to 96%).

Summary of Evidence
For individuals who have end-stage renal disease without contraindications to kidney transplant who receive a kidney transplant from a living donor or deceased (cadaveric) donor, the evidence includes registry data and case series. Relevant outcomes are OS, morbid events, and treatment-related mortality and morbidity. Data from large registries have demonstrated reasonably high survival rates after kidney transplant for appropriately selected patients and significantly higher survival rates for patients undergoing kidney transplant compared with those who remained on a waiting list. Kidney transplantation is contraindicated for patients in whom the procedure is expected to be futile due to comorbid disease or in whom posttransplantation care is expected to significantly worsen comorbid conditions. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have a failed kidney transplant without contraindications to kidney transplant who receive a kidney retransplant from a living donor or deceased (cadaveric) donor, the evidence includes registry data and case series. Relevant outcomes are OS, morbid events, and treatment-related mortality and morbidity. Data have demonstrated reasonably high survival rates after kidney retransplant (e.g., 5-year survival rates ranging from 87% to 96%) for appropriately selected patients. Kidney retransplantation is contraindicated for patients for whom the procedure is expected to be futile due to comorbid disease or for whom posttransplantation care is expected to significantly worsen comorbid conditions. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

The purpose of the following information is to provide reference material. Inclusion does not imply endorsement or alignment with the evidence review conclusions.

Practice Guidelines and Position Statements
Guidelines or position statements will be considered for inclusion in ‘Supplemental Information' if they were issued by, or jointly by, a U.S. professional society, an international society with U.S. representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

American Society of Transplant Surgeons et al.
In 2011, the American Society of Transplant Surgeons, the American Society of Transplantation, the Association of Organ Procurement Organizations, and the UNOS issued a joint position statement recommending modifications to the National Organ Transplant Act of 1984.³⁰ The joint recommendation stated that the potential pool of organs from HIV-infected donors should be explored. With modern antiretroviral therapy, the use of these previously banned organs would open an additional pool of donors to HIV-infected recipients. The increased pool of donors has the potential to shorten wait times for organs and decrease the number of waiting list deaths. The organs from HIV-infected deceased donors would be used for transplant only with patients already infected with HIV. In 2013, the HIV Organ Policy Equity Act permitted the use of this group of organ donors.

U.S. Preventive Services Task Force Recommendations
Not applicable.

Ongoing and Unpublished Clinical Trials
Some currently unpublished trials that might influence this review are listed in Table 2.

Table 2. Summary of Key Trials

NCT No.	Trial Name	Planned Enrollment	Completion Date
Ongoing
NCT04182607	Donor Outcomes Following Hand-Assisted And Robotic Living Donor Nephrectomy: A Retrospective Review	240	Nov 2020
NCT03500315	HOPE in Action Prospective Multicenter, Clinical Trial of Deceased HIVD+ Kidney Transplants for HIV+ Recipients	160	Aug 2022

NCT: national clinical trial.

References  

1. Black CK, Termanini KM, Aguirre O, et al. Solid organ transplantation in the 21 st century. Ann Transl Med. Oct 2018; 6(20): 409. PMID 30498736
2. United Network for Organ Sharing (UNOS). Transplant trends. Updated May 17, 2022; https://unos.org/data/transplant-trends/. Accessed June 10, 2022
3. Organ Procurement and Transplantation Network. View Data Reports. n.d.; https://optn.transplant.hrsa.gov/data/view-data-reports/. Accessed June 10, 2022.
4. National Kidney Foundation. Glomerular Filtration Rate (GFR). n.d.; https://www.kidney.org/atoz/content/gfr. Accessed June 10, 2022.
5. US Department of Health & Human Services. Educational guidance on patient referral to kidney transplantation. September 2015; https://optn.transplant.hrsa.gov/resources/guidance/educational-guidance-on-patient-referral-to-kidney-transplantation/. Accessed June 10, 2022.
6. United Network for Organ Sharing (UNOS). How we match organs. 2022. https://unos.org/transplant/how-we-match-organs/. Accessed June 10, 2022.
7. Organ Procurement and Transplantation Network (OPTN). OPTN policies. Updated April 28, 2022. https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf. Accessed June 10, 2022.
8. Chaudhry D, Chaudhry A, Peracha J, et al. Survival for waitlisted kidney failure patients receiving transplantation versus remaining on waiting list: systematic review and meta-analysis. BMJ. Mar 01 2022; 376: e068769. PMID 35232772
9. Krishnan N, Higgins R, Short A, et al. Kidney Transplantation Significantly Improves Patient and Graft Survival Irrespective of BMI: A Cohort Study. Am J Transplant. Sep 2015; 15(9): 2378-86. PMID 26147285
10. Querard AH, Foucher Y, Combescure C, et al. Comparison of survival outcomes between Expanded Criteria Donor and Standard Criteria Donor kidney transplant recipients: a systematic review and meta-analysis. Transpl Int. Apr 2016; 29(4): 403-15. PMID 26756928
11. Pestana JM. Clinical outcomes of 11,436 kidney transplants performed in a single center - Hospital do Rim. J Bras Nefrol. Jul-Sep 2017; 39(3): 287-295. PMID 28902233
12. Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long-term survival following live kidney donation. JAMA. Mar 10 2010; 303(10): 959-66. PMID 20215610
13. Muller E, Barday Z, Mendelson M, et al. HIV-positive-to-HIV-positive kidney transplantation--results at 3 to 5 years. N Engl J Med. Feb 12 2015; 372(7): 613-20. PMID 25671253
14. Locke JE, Reed RD, Mehta SG, et al. Center-Level Experience and Kidney Transplant Outcomes in HIV-Infected Recipients. Am J Transplant. Aug 2015; 15(8): 2096-104. PMID 25773499
15. Locke JE, Mehta S, Reed RD, et al. A National Study of Outcomes among HIV-Infected Kidney Transplant Recipients. J Am Soc Nephrol. Sep 2015; 26(9): 2222-9. PMID 25791727
16. Locke JE, Gustafson S, Mehta S, et al. Survival Benefit of Kidney Transplantation in HIV-infected Patients. Ann Surg. Mar 2017; 265(3): 604-608. PMID 27768622
17. Sawinski D, Forde KA, Eddinger K, et al. Superior outcomes in HIV-positive kidney transplant patients compared with HCV-infected or HIV/HCV-coinfected recipients. Kidney Int. Aug 2015; 88(2): 341-9. PMID 25807035
18. Zheng X, Gong L, Xue W, et al. Kidney transplant outcomes in HIV-positive patients: a systematic review and meta-analysis. AIDS Res Ther. Nov 20 2019; 16(1): 37. PMID 31747972
19. Working Party of the British Transplantation Society. Kidney and Pancreas Transplantation in Patients with HIV. Second Edition (Revised). 2017. https://bts.org.uk/wp-content/uploads/2017/04/02_BTS_Kidney_Pancreas_HIV.pdf. Accessed June 10, 2022.
20. Fabrizi F, Martin P, Dixit V, et al. Meta-analysis of observational studies: hepatitis C and survival after renal transplant. J Viral Hepat. May 2014; 21(5): 314-24. PMID 24716634
21. Gill JS, Lan J, Dong J, et al. The survival benefit of kidney transplantation in obese patients. Am J Transplant. Aug 2013; 13(8): 2083-90. PMID 23890325
22. Pieloch D, Dombrovskiy V, Osband AJ, et al. Morbid obesity is not an independent predictor of graft failure or patient mortality after kidney transplantation. J Ren Nutr. Jan 2014; 24(1): 50-7. PMID 24070588
23. Kwan JM, Hajjiri Z, Metwally A, et al. Effect of the Obesity Epidemic on Kidney Transplantation: Obesity Is Independent of Diabetes as a Risk Factor for Adverse Renal Transplant Outcomes. PLoS One. 2016; 11(11): e0165712. PMID 27851743
24. Kervinen MH, Lehto S, Helve J, et al. Type 2 diabetic patients on renal replacement therapy: Probability to receive renal transplantation and survival after transplantation. PLoS One. 2018; 13(8): e0201478. PMID 30110346
25. Lim WH, Wong G, Pilmore HL, et al. Long-term outcomes of kidney transplantation in people with type 2 diabetes: a population cohort study. Lancet Diabetes Endocrinol. Jan 2017; 5(1): 26-33. PMID 28010785
26. Barocci S, Valente U, Fontana I, et al. Long-term outcome on kidney retransplantation: a review of 100 cases from a single center. Transplant Proc. May 2009; 41(4): 1156-8. PMID 19460504
27. Kainz A, Kammer M, Reindl-Schwaighofer R, et al. Waiting Time for Second Kidney Transplantation and Mortality. Clin J Am Soc Nephrol. Jan 2022; 17(1): 90-97. PMID 34965955
28. Gupta M, Wood A, Mitra N, et al. Repeat Kidney Transplantation After Failed First Transplant in Childhood: Past Performance Informs Future Performance. Transplantation. Aug 2015; 99(8): 1700-8. PMID 25803500
29. Shelton BA, Mehta S, Sawinski D, et al. Increased Mortality and Graft Loss With Kidney Retransplantation Among Human Immunodeficiency Virus (HIV)-Infected Recipients. Am J Transplant. Jan 2017; 17(1): 173-179. PMID 27305590
30. American Society of Transplant Surgeons (ASTS), The American Society of Transplantation (AST), The Association of Organ Procurement Organizations (AOPO), et al. Statement on transplantation of organs from HIV-infected deceased donors. 2011; https://asts.org/docs/default-source/position-statements/transplantation-of-organs-from-hiv-infected-deceased-donors-july-22-2011.pdf?sfvrsn=fbae5a20_4. Accessed June 10, 2022.
31. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 11 - End Stage Renal Disease (ESRD). 2019; https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c11.pdf. Accessed June 10, 2022.

Coding Section

Codes	Number	Description
CPT	50300	Donor nephrectomy (including cold preservation), from cadaver, unilateral or bilateral
	50320	As above, but from living donor
	50323	Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches as necessary
	50325	Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches as necessary
	50327	Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each
	50328	arterial anastomosis, each
	50329	ureteral anastomosis, each
	50340	Recipient nephrectomy
	50360	Renal allotransplantation; implantation of graft without recipient nephrectomy
	50365	As above, but with recipient nephrectomy
	50547	Laparoscopy, surgical; donor nephrectomy (including cold preservation) from living donor
ICD-9 Procedure	55.51	Nephroureterectomy
	55.54	Bilateral nephrectomy
	55.69	Other kidney transplant
ICD-9 Diagnosis	585.1-585.9	Chronic kidney disease (previously known as chronic renal failure) code range (see Policy Guidelines section for specific codes for underlying etiologies)
HCPCS		No Code
ICD-10-CM (effective 10/01/15)	N18.1-18.9	Chronic kidney disease (CKD) code range
	N13.8	Other obstructive and reflux uropathy
	N13.9	Obstructive and refux uropathy unspecified
	M32.9	Systemic lupus erthematosus unspecified
	M32.0-M32.8	Systemic lupus erythematosus
	M31.30, M31.31	Wegner's granulomatosis
	N17.1	Acute kidney failure with acute cortical necrosis
	D69.0	Allergic purpura
	D59.3	Hemolytic-uremic syndrome
	N17.0	Acute kidney failure with tubular necrosis
	N26.9	Renal sclerosis nos
	N28.0	Ischemia and infarction of kidney
	N11.9	Chronic tubule-interstitial nephritis unspecified
	N05.0-N05.9	Unspecified nephritic syndrome unspecified code range
	N03.0-N03.9	chronic nephritic syndrome code range
	T45.8x1-T45.8x6	Poisoning by adverse effect of an underdosing of other primarily systemic and hematologic agents code range
	Q61.11-Q61.3	Polycystic kidney disease code range
	Q61.5	Medullary cystic kidney
	E83.50-E83.59	Disorders of calcium metabolism code range
	M10.30-M10.39	Gout due to renal impairment code range
	E85.0-E85.9	Amyloidosis code range
	E77.0-E77.9	Disorders of glycoprotein metabolism code range
	E72.4	Disorders of ornithine metabolism
	E74.8	Other specified disorders of carbohydrate metabolism
	E74.9	Unspecified disorders of carbohydrate metabolism
	Q63.0-Q63.9	Other congenital malformations of the kdney code range
	Q61.9	Cystic kidney disease unspecified
	Q60.0-Q60.6	Renal agenesis and other defects code range
	C90.00-C90.02	Multiple myeloma remission code range
	Q85.1	Tuberous sclerosis
	S37.00-S37.099	Injury of kidney code range
ICD-10-PCS (effective 01/01/15)	0TT00ZZ	Surgical, resection of right kidney, open
	0TT04ZZ	Surgical, resection of right kidney, percutaneous endoscopic
	0TT10ZZ	Surgical, resection of left kidney, open
	0TT14ZZ	Surgical, resection of left kidney, percutaneous endoscopic
	0TY00Z0	Surgical, transplantation of right kidney, allogeneic, open approach
	0TY10Z0	Surgical, transplantation of left kidney, allogeneic, open approach
Type of Service	Surgery
Place of Service	Inpatient

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

Index
Kidney Transplant
Renal Transplant
Transplant, Renal

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.All Rights Reserved" 

History From 2013 Forward     

12/072022	Annual review, no change to policy intent. Updating rationale and references
12/07/2021	Annual review, no change to policy intent. Updating guidelines, rationale and references.
12/01/2020	Annual review, no change to policy intent. Updating background, rationale and references.
12/03/2019	Annual review, no change to policy intent. Updating regulatory status, rationale and references.
12/20/2018	Annual review, no change to policy intent. Updating rationale and references.
12/20/2017	Annual review, no change to policy intent. Updating background, description, benefit application, rationale and references.
12/01/2016	Annual review, no change to policy intent.
12/07/2015	Annual review, no change to policy intent. Updated background, description, rationale and references.
12/01/2014	Annual review, no change to policy intent. Added coding and key words. Updated policy verbiage "Kidney transplant is considered investigational in all other situations."
12/5/2013	Annual review. Updated policy verbiage to include "kidney retransplant after a failed primary kidney transplant may be considered medically necessary", updated rationale & references, adding benefit application.