Outcomes of Liver Transplantation in Patients on Renal Replacement Therapy: Considerations for Simultaneous Liver Kidney Transplantation Versus Safety Net

Abstract

What problem will this proposal solve? Current OPTN policy prioritizes candidates seeking a simultaneous liver kidney (SLK) transplant before pediatric and adult transplant candidates who are listed only for a kidney ("kidney alone candidates") when the liver candidate and the deceased donor are in the same Donation Service Area (DSA) 1. Unlike kidney alone allocation, in SLK allocation, the kidney is not allocated based on medical criteria assessing the kidney function of the candidate. Instead, geographic proximity between the liver-kidney candidate and the donor is the single factor in allocating the kidney with the liver. OPOs are not required to allocate the kidney with the liver regionally, although they are given the discretion to do so. The Kidney Transplantation Committee ("the Committee"),has identified several problems with this current policy:

Immunosuppressive regimens for adult liver transplant recipients in real-life practice: consensus recommendations from an Italian Working Group

“…Combined liver-kidney transplantation should be considered in patients with severe renal impairment or on renal replacement therapy [ 30 , 31 ].…”

“…Patients with ADPKD and renal impairment and/or in renal replacement therapy are considered for simultaneous or delayed combined liver-kidney transplantation [ 43 , 44 ]. In this case, the immunosuppressive therapy is directed towards the critical patient path or towards the standard case path depending on the clinical conditions and after a careful multidisciplinary evaluation [ 30 , 31 ].…”

Simultaneous liver kidney allocation policy and the Safety Net: an early examination of utilization and outcomes in the United States

“…Recent studies have sought to define the specific ESLD population who best benefit from dual organ transplantation. These showed that SLK improved graft survival in patients with prolonged dialysis-dependent renal failure [6,10] but did not in nondialysisdependent patients [6,11,12]. The ongoing concern is that unregulated renal allograft allocation for SLK reduces organ availability for renal failure patients requiring isolated kidney transplant.…”

Current and Evolving Indications for Simultaneous Liver Kidney Transplantation

“…12 A more recent analysis corroborated this and also noted that of patients listed for SLK who underwent LTA prior to 2017, only 7.4% underwent KALT within the first 3 years post LTA. 72 Finally, although previous data had reported superior patient and graft survival in SLK compared with KALT, newer data have shown equivalent outcomes with early KALT. [73][74][75] Thus, an expeditious pathway to KALT is necessary to allow LTA over SLK but to also avoid prolonged KALT wait times and mortality.…”