The critical role of testing for transplant donors and recipients
In the fall of 2022, the United States reached a historic and critical milestone — its organ donation system surpassed 1 million organ transplants, more than any other country in the world.1 Each of these 1 million organs represents an individual living with a condition that requires exceptional care. These patients must endure ongoing post-transplant monitoring, anti-rejection medications, and other therapies. Post-transplant, patients can require anywhere between 10 and 20 years of monitoring, on average, and will need as many as 500 diagnostic tests throughout their lives.2 Making this process as convenient as possible, and eliminating barriers to receiving this testing, is essential for transplant patients to achieve the best health outcomes. Yet, this is only one piece of the larger transplant patient journey.
The rising trend of living donation for transplant patients
In the United States, the most transplanted organs are the kidney, liver, heart, lungs, pancreas, and intestines. Some of these, like the heart, can only be transplanted from cadavers, or deceased donors. Others, like the kidney, can come from a living donor — a procedure that is often associated with more favorable outcomes, including lower risk of complications. Living donation is also associated with shorter hospital stays and related cost savings post-surgery. While most patients receive organs from cadavers, in 2021, over 6,500 transplants were performed from living donors — an increase of 14.2 percent over 2020.3
Furthermore, if a person is able to secure a living donor, it reduces their need to wait for a cadaver, saving not only their life, but potentially the lives of other patients who may be waiting with them for the next available organ. Though living donation is most common in the case of kidney transplants, recent years have seen a rise in living donation for partial liver transplants, which are also associated with better outcomes as the less time a harvested liver is artificially preserved, the better.4
These trends have been made possible by the emergence of new guidelines and further advancements in testing. As one example, providers now have improved methods to test donors and patients to determine match compatibility. This has helped match patients with HIV with donors who also have HIV, enabling care for people who previously had limited access. Yet, this is only one piece of how providers can work together to improve ability to access services.5
Broadening convenient access to transplant services and eliminating barriers to testing
Access to fast and convenient transplant testing services is vital for transplant donors and recipients. Testing provides invaluable insights to identify infectious diseases in donors and recipients, determine match compatibility, monitor transplant therapy response, and identify rejection. Given certain transplant therapies may suppress the immune system, testing is also crucial to identify pathogens to help prevent transmission from a donor.
While patient compliance in testing is critical, several factors can impede a patient’s ability to receive testing, which can ultimately contribute to poor outcomes, such as late acute rejection. As an example, long travel times and inflexible scheduling can worsen a patient’s access, ultimately lowering the likelihood of compliance. It is important, therefore, to meet transplant patients where they are, and invest in their care. By offering a mobile testing option, both transplant recipients and living donors can complete specimen collection at a time and place convenient for them, especially when they may be at suboptimal health. It is important for providers to continue to find ways to remove barriers to care and increase access to testing.
Additionally, a hospital or transplant center can work with a collaborator to improve logistics access by offering specimen collection through a nationwide network of patient access points. This is particularly critical in cases where a living donor or recipient lives far from the institution that will or has performed the transplant procedure. By working with a testing provider, patients may cut down on otherwise excessive travel times and see benefits related to scheduling and walk-in appointment availability.
As one example, when we heard from clients that our transplant offering needed improvements, we made efforts to streamline patient education, help phlebotomists fast-track specimens, decrease turnaround times, and increase access to at-home testing through our ExamOne mobile phlebotomy business. Yale New Haven Hospital in Connecticut, which piloted the improved transplant offering we debuted earlier this year, has said that working with us has helped expand access for patients who previously would have had to visit a transplant center to receive testing — in many cases, one that was extremely far from a patient’s home. Other clients have reported the same, and that reducing patient noncompliance has eased strain from overloaded health system workers who lacked the time needed for follow-up.
Exploring advancements in transplant testing: How genetic testing can impact patients
Beyond the traditional battery of tests associated with transplantation, advanced genetic tests may also provide invaluable insights for donors and recipients.
Genetic testing is traditionally used to identify differences in a person’s DNA that can influence the way their cells function. Examining these DNA variants is often useful for both identifying a person’s risk of disease development and the likelihood that a certain disease might respond to a specific therapy. Different types of genetic tests look for different kinds of DNA variants, and sometimes different combinations of genetic variations.
There are many different technologies that can help detect genetic variations. For transplant patients, these tests are most often utilized when assessing kidney recipients or donors. Specifically, the National Institute of Health cites three main applications of genetic testing in clinical kidney transplantation: (1) the risk assessment of donors, (2) disease characterization of recipients, and (3) improving drug selection and dosing for recipients using pharmacogenomic data.6
One such test, Apolipoprotein L1 (APOL1) renal risk variant genotyping, is an advanced genetic test to help evaluate kidney disease risk for donors. The test identifies those who have a “high-risk genotype,” and increased susceptibility to certain types of non-diabetic kidney disease, compared to individuals with a “low-risk genotype.” Data shows the APOL1 status of the donor can impact post-donation renal function in the donor and recipient.7
It is worthwhile to explore whether genetics affect donor suitability, particularly for those with a family history of cystic kidney disease. As living donations become more popular, genetic testing may also see an uptick in utilization. Its assessments can be valuable in both determining match favorability and understanding risks for both donors and recipients, so that when working with a physician, the appropriate actions can be taken.
Conclusion: Improving testing availability remains a priority for providers
As the number of yearly transplants increases nationwide, and as younger patients receive more transplants, the need for more testing and monitoring over a longer period will also continue to increase.
Health systems and healthcare professionals caring for these vulnerable patients need to consider not just quality of testing but also location in order to optimize patient compliance. When the health of the patient is centered in all care decisions, the best outcomes for all parties can be achieved.
References
1. Bryant C. U.S. reaches historic milestone of 1 million organ transplants. The Organ Donation and Transplantation Alliance. Published September 9, 2022. Accessed August 7, 2023. https://www.organdonationalliance.org/alliance-news/u-s-reaches-historic-milestone-of-1-million-organ-transplants/.
2. Quest Diagnostics. Data on file. 2020. Based on the number of individual tests run and frequency of testing heard for a typical patient.
3. All-time records again set in 2021 for organ transplants, organ donation from deceased donors - OPTN. Hrsa.gov. Accessed August 7, 2023. https://optn.transplant.hrsa.gov/news/all-time-records-again-set-in-2021-for-organ-transplants-organ-donation-from-deceased-donors/.
4. Live-donor liver transplants on the rise at johns Hopkins. Hopkinsmedicine.org. Accessed August 7, 2023. https://www.hopkinsmedicine.org/news/articles/live-donor-liver-transplants-on-the-rise-at-johns-hopkins.
5. OPTN policies to align with 2020 U.S Public Health Service Guideline - OPTN. Hrsa.gov. Accessed August 7, 2023. https://optn.transplant.hrsa.gov/professionals/by-topic/patient-safety/optn-policies-to-align-with-2020-us-public-health-service-guideline/.
6. Marin EP, Cohen E, Dahl N. Clinical applications of genetic discoveries in kidney transplantation: A review. Kidney360. 2020;1(4):300-305. doi:10.34067/KID.0000312019.
7. Apolipoprotein L1 (APOL1) renal risk variant genotyping. Questdiagnostics.com. Accessed August 7, 2023. https://www.questdiagnostics.com/healthcare-professionals/clinical-education-center/faq/faq287.
