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

Abstract

Rates of simultaneous liver kidney (SLK) transplantation in the United States have progressively risen. On 8/10/17, the Organ Procurement and Transplantation Network implemented a policy defining criteria for SLK, with a "Safety Net" to prioritize kidney allocation to liver recipients with ongoing renal failure. We performed a retrospective review of the United Network for Organ Sharing (UNOS) database to evaluate policy impact on SLK, kidney after liver (KAL) and kidney transplant alone (KTA). Rates and outcomes of SLK and KAL transplants were compared, as was utilization of high-quality kidney allografts with Kidney Donor Profile Indices (KDPI) <35%. Here, SLK transplants comprised 9.0% and 4.5% of total postpolicy liver and kidney transplants compared to 10.2% and 5.5% prior. Policy enactment did not affect 1-year graft or patient survival for SLK and KAL populations. Less postpolicy SLK transplants utilized high-quality kidney allografts; in all transplant settings, outcomes using high-quality grafts remained stable. These findings suggest that policy implementation has reduced kidney allograft use in SLK transplantation, although both SLK and KAL rates have recently increased. Despite decreased high-quality kidney allograft use, SLK and KAL outcomes have remained stable. Additional studies and long-term follow-up will ensure optimal organ access and sharing.

Kidney utilization and outcomes of liver transplant recipients who were listed for kidney after liver transplant after the implementation of safety net policy

“…Similar to prior studies, sensitization is not a major issue for the safety net patients as median PRA remains at zero at listing and time of KT. 10 Several studies have noted a decrease in prevalence of viral hepatitis in the SLK population 10,11 reflecting the impact of the direct acting antiviral (DAA) therapy. Currently, the American Association for the Study of Liver Diseases (AASLD) and the US Preventive Services Task Force advocate for one time screening for hepatitis C of individuals aged 18 years or older.…”

Differential Impact of the UNOS Simultaneous Liver-kidney Transplant Policy Change Among Patients With Sustained Acute Kidney Injury

“…Importantly, although infrequently used, the “Safety Net” kidney allocation provided an important protection for patients who did not recover sufficient native kidney function after LTA. 24-26 Our findings suggest that the “Safety Net” kidney allocation adequately rescued non-Black patients who lost the SLK eligibility after the 2017 policy change.…”

One size does not fit all: Differential benefits of simultaneous liver-kidney transplantation by eligibility criteria

“…[1] The Safety Net has been heavily utilized, and outcomes are favorable. [9][10][11][12][13] Staged liver-kidney transplantation, where a kidney transplant follows a liver transplant a few months later if kidney function does not recover after liver transplantation, may be a viable alternative to or even superior to SLK in subsets of patients.…”

“…A second part of the 2017 SLK allocation change is the “Safety Net,” whereby liver transplant recipients who develop ESKD within 1 year of the liver transplant gain priority access to deceased donor kidney transplant over other kidney transplant waitlist candidates 1 . The Safety Net has been heavily utilized, and outcomes are favorable 9–13 . Staged liver-kidney transplantation, where a kidney transplant follows a liver transplant a few months later if kidney function does not recover after liver transplantation, may be a viable alternative to or even superior to SLK in subsets of patients.…”