To kidney or not to kidney: Applying lessons learned from the simultaneous liver‐kidney transplant policy to simultaneous heart‐kidney transplantation

Abstract

As the medical community is increasingly offering transplantation to patients with increasing comorbidity burdens, the number of simultaneous heart‐kidney (SHK) transplants is rising in the United States. How to determine eligibility for SHK transplant versus heart transplant alone is unknown. In this review, we situate this problem in the broader picture of organ shortage. We critically appraise available literature on outcomes in SHK versus heart transplant alone. We posit staged kidney‐after‐heart transplantation as a plausible alternative to SHK transplantation and review the pros and cons. Drawing lessons from the field of simultaneous liver‐kidney transplant, we argue for an analogous policy for SHK transplant with standardized minimal eligibility criteria and a modified Safety Net provision. The new policy will serve as a starting point for comparing simultaneous versus staged approaches and refining the medical eligibility criteria for SHK.

Optimal patient selection for simultaneous heart-kidney transplant: A modified cost-effectiveness analysis

“…Our study is the first to demonstrate quantitatively what many have argued on qualitative grounds 3,14,17,20–24 —that unconstrained use of multi‐organ transplants, including SHK, fails to maximize the benefit from a limited supply of deceased donor kidneys. This finding supports the adoption of standard eligibility criteria for SHK combined with a Safety Net provision.…”

“…20 A consistent finding is that this benefit is greater among patients with more advanced kidney dysfunction prior to transplant. [12][13][14]20 Our model incorporates such heterogeneity by assuming that SHK reduces mortality only for patients who do not experience kidney recovery with HT-only. Acknowledging that this parameter is both influential and uncertain, we present a two-way sensitivity analysis that varies the SHK mortality benefit over a wide range.…”

“…All are observational and subject to potential selection bias, which could exaggerate the apparent benefit of SHK 20 . A consistent finding is that this benefit is greater among patients with more advanced kidney dysfunction prior to transplant 12–14,20 . Our model incorporates such heterogeneity by assuming that SHK reduces mortality only for patients who do not experience kidney recovery with HT‐only.…”

“…To stem such "overuse" of kidneys for SHK, many have advocated for standardized SHK eligibility requirements 3,14,17,[20][21][22][23][24] and an accompanying Safety Net provision. [20][21][22] No studies have provided quantitative support for this policy.…”

CKD in Recipients of Nonkidney Solid Organ Transplants: A Review

“…Efforts to implement a similar policy for simultaneous heartkidney transplant are underway, with consensus recommendations modeled after the UNOS SLK policy. 65,66 Beyond allocation policy, a number of emerging approaches to the prevention and treatment of CKD following SOT deserve further study. Clinical risk tools are available to predict those liver transplant candidates at most risk of kidney failure 5 years following transplant that could be used for further risk stratification.…”