Utility in treating renal failure in end-stage liver disease with simultaneous liver-kidney transplantation. Transplantation. 2016;. [PMID: 28437790 PMCID: PMC5079265 DOI: 10.1097/tp.0000000000001491]

Differential in Kidney Graft Years on the Basis of Solitary Kidney, Simultaneous Liver-Kidney, and Kidney-after-Liver Transplants

BACKGROUND

The number of simultaneous liver-kidney (SLK) transplants has significantly increased in the United States. There has also been an increase in kidney-after-liver transplants associated with 2017 policy revisions aimed to fairly allocate kidneys after livers. SLK and kidney-after-liver candidates are prioritized in allocation policy for kidney offers ahead of kidney-alone candidates.

METHODS

We compared kidney graft outcomes of kidney-alone transplant recipients with SLK and kidney-after-liver transplants using paired kidney models to mitigate differences among donor risk factors. We evaluated recipient characteristics between transplant types and calculated differential graft years using restricted mean survival estimates.

RESULTS

We evaluated 3053 paired donors to kidney-alone and SLK recipients and 516 paired donors to kidney-alone and kidney-after-liver recipients from August 2017 to August 2022. Kidney-alone recipients were younger, more likely on dialysis, and Black race. One-year and 3-year post-transplant kidney graft survival for kidney-alone recipients was 94% and 86% versus SLK recipients 89% and 80%, respectively, P < 0.001. One-year and 3-year kidney graft survival for kidney-alone recipients was 94% and 84% versus kidney-after-liver recipients 93% and 87%, respectively, P = 0.53. The additional kidney graft years for kidney-alone versus SLK transplants was 21 graft years/100 transplants (SEM=5.0) within 4 years post-transplantation, with no significant difference between kidney-after-liver and kidney-alone transplants.

CONCLUSIONS

Over a 5-year period in the United States, SLK transplantation was associated with significantly lower kidney graft survival compared with paired kidney-alone transplants. Most differences in graft survival between SLK and kidney-alone transplants occurred within the first year post-transplantation. By contrast, kidney-after-liver transplants had comparable graft survival with paired kidney-alone transplants.

Incidence of Kidney Failure after Primary Organ Transplant

Key Points

Incidence of ESKD in the first year after primary organ transplant ranges from 2.4% to 3.6% and from 1.4% to 1.8% in the second year post-transplant. National data sources do not currently collect sufficiently reliable follow-up data to identify pretransplant predictors of ESKD.

Background

Careful selection of multiorgan transplant candidates is required to avoid unintended consequences to patients waiting for kidney transplant alone. The need for a safety net among heart and lung transplant recipients is unknown. The objective of this study was to quantify the incidence of kidney failure after liver, heart, or lung transplantation and identify pretransplant predictors of post-transplant kidney failure.

Methods

A retrospective cross-sectional study of adults who received liver, heart, or lung transplant between January 1, 2008, and December 31, 2018, was conducted using data from the Scientific Registry of Transplant Recipient and the United States Renal Data System. Post-transplant renal failure was defined as (1 ) new start of dialysis, (2 ) eGFR of <25 ml/min, (3 ) a new waitlisting for a kidney transplant, or (4 ) receipt of a kidney transplant.

Results

The final descriptive cohort included 53,620 liver transplant recipients, 22,042 heart transplant recipients, and 10,688 lung transplant recipients. In the first year post-transplant, the probability of ESKD was comparable among heart transplant recipients (0.036; 95% confidence interval [CI], 0.033 to 0.038) and liver transplant recipients (0.033; 95% CI, 0.031 to 0.035) but was markedly lower in lung transplant recipients (0.024; 95% CI, 0.021 to 0.027). In the second year post-transplant, the probability of ESKD was comparable among liver (0.016; 95% CI, 0.015 to 0.017), lung (0.018; 95% CI, 0.015 to 0.021), and heart transplant recipients (0.014; 95% CI, 0.013 to 0.016).

Conclusions

Candidates for thoracic transplant would likely benefit from a safety net policy similar to the one enacted in 2017 for liver transplant so as to maintain judicious patient selection for simultaneous multiorgan transplant. National data sources do not currently collect sufficiently reliable follow-up data to identify pretransplant predictors of ESKD, pointing to a need for transplant centers to consistently report kidney impairment data to national databases.

Recent advances in pathophysiology, diagnosis and management of hepatorenal syndrome: A review

Hepatorenal syndrome with acute kidney injury (HRS-AKI) is a form of rapidly progressive kidney dysfunction in patients with decompensated cirrhosis and/or acute severe liver injury such as acute liver failure. Current data suggest that HRS-AKI occurs secondary to circulatory dysfunction characterized by marked splanchnic vasodilation, leading to reduction of effective arterial blood volume and glomerular filtration rate. Thus, volume expansion and splanchnic vasoconstriction constitute the mainstay of medical therapy. However, a significant proportion of patients do not respond to medical management. These patients often require renal replacement therapy and may be eligible for liver or combined liver-kidney transplantation. Although there have been advances in the management of patients with HRS-AKI including novel biomarkers and medications, better-calibrated studies, more widely available biomarkers, and improved prognostic models are sorely needed to further improve diagnosis and treatment of HRS-AKI.

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

Increasing rates of simultaneous heart-kidney (SHK) transplant in the United States exacerbate the overall shortage of deceased donor kidneys (DDK). Current allocation policy does not impose constraints on SHK eligibility, and how best to do so remains unknown. We apply a decision-analytic model to evaluate options for heart transplant (HT) candidates with comorbid kidney dysfunction. We compare SHK with a "Safety Net" strategy, in which DDK transplant is performed 6 months after HT, only if native kidneys do not recover. We identify patient subsets for whom SHK using a DDK is efficient, considering the quality-adjusted life year (QALY) gains from DDKs instead allocated for kidney transplant-only. For an average-aged candidate with a 50% probability of kidney recovery after HT-only, SHK produces 0.64 more QALYs than Safety Net at a cost of 0.58 more kidneys used. SHK is inefficient in this scenario, producing fewer QALYs per DDK used (1.1) than a DDK allocated for KT-only (2.2). SHK is preferred to Safety Net only for candidates with a lower probability of native kidney recovery (24%-38%, varying by recipient age). This finding favors the implementation of a Safety Net provision and should inform the establishment of objective criteria for SHK transplant eligibility.

Impact of Advanced Renal Dysfunction on Posttransplant Outcomes After Living Donor Liver Transplantation in the United States

BACKGROUND

Survival after living donor liver transplantation (LDLT) in the United States is excellent. However, the significance of pretransplant kidney disease on outcomes in this population is poorly understood.

METHODS

This was a retrospective cohort study of 2806 LDLT recipients nationally between January 2010 and June 2020. Recipients with estimated glomerular filtration rate <40 mL/min/1.73 m2 (eGFR-low) or requiring dialysis were compared. Multivariable survival analyses evaluated (1) eGFR-low as a predictor of post-LDLT survival and (2) the survival of LDLT versus deceased donor liver transplant (DDLT) alone with eGFR-low.

RESULTS

From 2010 to 2020, 140 (5.0%) patients had eGFR-low and 18 (0.6%) required dialysis pre-LDLT. The number of LDLTs requiring dialysis between 2017 and 2020 outnumbered the prior 7 y. Overall LDLT experience was greater at centers performing LDLT in recipients with renal dysfunction (P < 0.001). LDLT recipients with eGFR-low had longstanding renal dysfunction: mean eGFR 3-6 mo before LDLT 42.7 (±15.1) mL/min/1.73 m2. Nearly half (5/12) of eGFR-low recipients with active kidney transplant (KT) listing at LDLT experienced renal recovery. Five patients underwent early KT after LDLT via the new "safety net" policy. Unadjusted survival after LDLT was worse with eGFR-low (hazard ratio 2.12 versus eGFR ≥40 mL/min/1.73 m2; 95% confidence interval, 1.47-3.05; P < 0.001), but no longer so when accounting for mean eGFR 3-6 mo pre-LDLT (hazard ratio, 1.27; 95% confidence interval, 0.82-1.95; P = 0.3). The adjusted survival of patients with eGFR-low receiving LDLT versus deceased donor liver transplant alone was not different (P = 0.08).

CONCLUSIONS

Overall, outcomes after LDLT with advanced renal dysfunction are acceptable. These findings are relevant given the recent "safety net" KT policy.

Current State of Multiorgan Transplantation and Implications for Future Practice and Policy

The incidence of kidney dysfunction has increased in liver transplant and heart transplant candidates, reflecting a changing patient population and allocation policies that prioritize the most urgent candidates. A higher burden of pretransplant kidney dysfunction has resulted in a substantial rise in the utilization of multiorgan transplantation (MOT). Owing to a shortage of available deceased donor kidneys, the increased use of MOT has the potential to disadvantage kidney-alone transplant candidates, as current allocation policies generally provide priority for MOT candidates above all kidney-alone transplant candidates. In this review, the implications of kidney disease in liver transplant and heart transplant candidates is reviewed, and current policies used to allocate organs are discussed. Important ethical considerations pertaining to MOT allocation are examined, and future policy modifications that may improve both equity and utility in MOT policy are considered.

The Impact of the 2017 Kidney Allocation Policy Change on Simultaneous Liver-Kidney Utilization and Outcomes

Historically in the United States, kidneys for simultaneous liver-kidney transplantation (SLKT) candidates were allocated with livers, prioritizing SLKT recipients over much of the kidney waiting list. A 2017 change in policy delineated renal function criteria for SLKT and implemented a safety net for kidney-after-liver transplantation. We compared the use and outcomes of SLKT and kidney-after-liver transplant with the 2017 policy. United Network for Organ Sharing Standard Transplant Analysis and Research files were used to identify adults who received liver transplantations (LT) from August 10, 2007 to August 10, 2012; from August 11, 2012 to August 10, 2017; and from August 11, 2017 to June 12, 2019. LT recipients with end-stage renal disease (ESRD) were defined by dialysis requirement or estimated glomerular filtration rate <25. We evaluated outcomes and center-level, regional, and national practice before and after the policy change. Nonparametric cumulative incidence of kidney-after-liver listing and transplant were modeled by era. A total of 6332 patients received SLKTs during the study period; fewer patients with glomerular filtration rate (GFR) ≥50 mL/min underwent SLKT over time (5.8%, 4.8%, 3.0%; P = 0.01 ). There was also less variability in GFR at transplant after policy implementation on center and regional levels. We then evaluated LT-alone (LTA) recipients with ESRD (n = 5408 from 2012-2017; n = 2321 after the policy). Listing for a kidney within a year of LT increased from 2.9% before the policy change to 8.8% after the policy change, and the rate of kidney transplantation within 1 year increased from 0.7% to 4% (P < 0.001). After the policy change, there was no difference in patient survival rates between SLKT and LTA among patients with ESRD. Implementation of the 2017 SLKT policy change resulted in reduced variability in SLKT recipient kidney function and increased access to deceased donor kidney transplantation for LTA recipients with kidney disease without negatively affecting outcomes.

The impact of multi-organ transplant allocation priority on waitlisted kidney transplant candidates

Kidney-alone transplant (KAT) candidates may be disadvantaged by the allocation priority given to multi-organ transplant (MOT) candidates. This study identified potential KAT candidates not receiving a given kidney offer due to its allocation for MOT. Using the Organ Procurement and Transplant Network (OPTN) database, we identified deceased donors from 2002 to 2017 who had one kidney allocated for MOT and the other kidney allocated for KAT or simultaneous pancreas-kidney transplant (SPK) (n = 7,378). Potential transplant recipient data were used to identify the "next-sequential KAT candidate" who would have received a given kidney offer had it not been allocated to a higher prioritized MOT candidate. In this analysis, next-sequential KAT candidates were younger (p < .001), more likely to be racial/ethnic minorities (p < .001), and more highly sensitized than MOT recipients (p < .001). A total of 2,113 (28.6%) next-sequential KAT candidates subsequently either died or were removed from the waiting list without receiving a transplant. In a multivariable model, despite adjacent position on the kidney match-run, mortality risk was significantly higher for next-sequential KAT candidates compared to KAT/SPK recipients (hazard ratio 1.55, 95% confidence interval 1.44, 1.66). These results highlight implications of MOT allocation prioritization, and potential consequences to KAT candidates prioritized below MOT candidates.

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

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.

Defining a Willingness-to-transplant Threshold in an Era of Organ Scarcity: Simultaneous Liver-kidney Transplant as a Case Example

BACKGROUND

Organ scarcity continues in solid organ transplantation, such that the availability of organs limits the number of people able to benefit from transplantation. Medical advancements in managing end-stage organ disease have led to an increasing demand for multiorgan transplant, wherein a patient with multiorgan disease receives >1 organ from the same donor. Current allocation schemes give priority to multiorgan recipients compared with single-organ transplant recipients, which raise ethical questions regarding equity and utility.

METHODS

We use simultaneous liver and kidney (SLK) transplant, a type of multiorgan transplant, as a case study to examine the tension between equity and utility in multiorgan allocation. We adapt the health economics willingness-to-pay threshold to a solid organ transplant setting by coining a new metric: the willingness-to-transplant (WTT) threshold.

RESULTS

We demonstrate how the WTT threshold can be used to evaluate different SLK allocation strategies by synthesizing utility and equity perspectives.

CONCLUSIONS

We submit that this new framework enables us to distill the question of SLK allocation down to: what is the minimum amount of benefit we require from a deceased donor kidney to allocate it for a particular indication? Addressing the above question will prove helpful to devising a rational system of SLK allocation and is applicable to other transplant settings.

Ethical decision-making in simultaneous heart-liver transplantation

PURPOSE OF REVIEW

Simultaneous heart-liver (SHL) transplants are only a small proportion of overall heart and liver transplantation, they have been increasing in frequency and thus challenge the equitable allocation of organs.

RECENT FINDINGS

The incidence of SHL transplants is reviewed along with the outcomes of SHL transplants and their impact on the waitlist, particularly in the context of solitary heart and liver transplantation. The ethical implications, most importantly the principles of utility and equity, of SHL transplant are addressed. In the context of utility, the distinction of a transplant being life-saving versus life-enhancing is investigated. The risk of hepatic decompensation for those awaiting both solitary and combined organ transplantation is an important consideration for the principle of equity. Lastly, the lack of standardization of programmatic approaches to SHL transplant candidates, the national approach to allocation, and the criteria by which programs are evaluated are reviewed.

SUMMARY

As with all multiorgan transplantation, SHL transplantation raises ethical issues of utility and equity. Given the unique patient population, good outcomes, lack of alternatives, and overall small numbers, we feel there is continued ethical justification for SHL, but a more standardized nationwide approach to the evaluation, listing, and allocation of organs is warranted.

Delayed Implantation of Pumped Kidneys Decreases Renal Allograft Futility in Combined Liver-Kidney Transplantation

BACKGROUND

Combined liver-kidney transplantation (CLKT) improves survival for liver transplant recipients with renal dysfunction; however, the tenuous perioperative hemodynamic and metabolic milieu in high-acuity CLKT recipients increases delayed graft function and kidney allograft failure. We sought to analyze whether delayed KT through pumping would improve kidney outcomes following CLKT.

METHODS

A retrospective analysis (University of California Los Angeles [n = 145], Houston Methodist Hospital [n = 79]) was performed in all adults receiving CLKT at 2 high-volume transplant centers from February 2004 to January 2017, and recipients were analyzed for patient and allograft survival as well as renal outcomes following CLKT.

RESULTS

A total of 63 patients (28.1%) underwent delayed implantation of pumped kidneys during CLKT (dCLKT) and 161 patients (71.9%) received early implantation of nonpumped kidneys during CLKT (eCLKT). Most recipients were high-acuity with median biologic model of end-stage liver disease (MELD) score of, 35 for dCLKT and 34 for eCLKT (P = ns). Pretransplant, dCLKT had longer intensive care unit stay, were more often intubated, and had greater vasopressor use. Despite this, dCLKT exhibited improved 1-, 3-, and 5-year patient and kidney survival (P = 0.02) and decreased length of stay (P = 0.001), kidney allograft failure (P = 0.012), and dialysis duration (P = 0.031). This reduced kidney allograft futility (death or continued need for hemodialysis within 3 mo posttransplant) for dCLKT (6.3%) compared with eCLKT (19.9%) (P = 0.013).

CONCLUSIONS

Delayed implantation of pumped kidneys is associated with improved patient and renal allograft survival and decreased hospital length of stay despite longer kidney cold ischemia. These data should inform the ethical debate as to the futility of performing CLKT in high-acuity recipients.

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

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.

Comparing Simultaneous Liver-Kidney Transplant Strategies: A Modified Cost-Effectiveness Analysis

BACKGROUND

The proportion of patients with kidney failure at time of liver transplantation is at a historic high in the United States. The optimal timing of kidney transplantation with respect to the liver transplant is unknown.

METHODS

We used a modified cost-effectiveness analysis to compare 4 strategies: the old system ("pre-OPTN"), the new Organ Procurement Transplant Network (OPTN) system since August 10, 2017 ("OPTN"), and 2 strategies which restrict simultaneous liver-kidney transplants ("safety net" and "stringent"). We measured "cost" by deployment of deceased donor kidneys (DDKs) to liver transplant recipients and effectiveness by life years (LYs) and quality-adjusted life years (QALYs) in liver transplant recipients. We validated our model against Scientific Registry for Transplant Recipients data.

RESULTS

The OPTN, safety net and stringent strategies were on the efficiency frontier. By rank order, OPTN > safety net > stringent strategy in terms of LY, QALY, and DDK deployment. The pre-OPTN system was dominated, or outperformed, by all alternative strategies. The incremental LY per DDK between the strategies ranged from 1.30 to 1.85. The incremental QALY per DDK ranged from 1.11 to 2.03.

CONCLUSIONS

These estimates quantify the "organ"-effectiveness of various kidney allocation strategies for liver transplant candidates. The OPTN system will likely deliver better liver transplant outcomes at the expense of more frequent deployment of DDKs to liver transplant recipients.

Effect of Renal Diagnosis on Survival in Simultaneous Liver-Kidney Transplantation

BACKGROUND

Simultaneous liver-kidney transplantation is lifesaving, however, the utility of allocating 2 organs to a single recipient remains controversial, particularly in the face of potentially inferior survival. This study aims to determine the effect of renal indication for transplantation on simultaneous liver-kidney transplantation outcomes.

METHODS

All adult recipients of combined whole liver-kidney transplants in the United Network for Organ Sharing database from 2003 to 2016 with a renal diagnosis of hypertension (HTN), diabetes mellitus (DM), acute tubular necrosis (ATN), or hepatorenal syndrome (HRS) were examined. Comparisons were made between the HTN/DM group and the ATN/HRS group using standard statistical methods.

RESULTS

There were 1,204 patients in the HRS/ATN group vs 1,272 patients in the HTN/DM group. The HTN/DM patients were slightly older (58.1 vs 56.4 years; p < 0.001), more likely to have liver disease due to chronic viral hepatitis (33.2% vs 21.5%; p < 0.001), and less acutely ill (mean Model for End-Stage Liver Disease score of 27.2 vs 33.1; p < 0.001) than their HRS/ATN counterparts. The prevalence of nonalcoholic steatohepatitis was 16.8% in both groups. Donor demographics were similar in both groups, although HTN/DM patients were more likely to have a local (81.6% vs 67.7%; p < 0.001) rather than regional donor. Patient survival rates at 1, 3, and 5 years were significantly lower in the HTN/DM group (87.4%, 78.2%, and 71.2% vs 90.7%, 84.1%, and 76.6%, respectively). Median survival was 118 months for the HTN/DM group vs 139.7 months for the HRS/ATN (p < 0.001). The HTN/DM patients were at significantly higher risk of death (hazard ratio 1.533; p < 0.001), liver graft loss (hazard ratio 1.611; p < 0.001), and renal graft loss (hazard ratio 1.592; p < 0.001) than ATN/HRS patients on multivariable analysis.

CONCLUSIONS

Despite a lower acuity of illness, HTN/DM patients have inferior survival after simultaneous liver-kidney transplantation than those with ATN/HRS. This should be considered in risk adjustment and allocation schemes.

Refining the Role of Simultaneous Liver Kidney Transplantation

Adoption of the model for end-stage liver disease score by Organ Procurement and Transplant Network (OPTN) deceased donor liver allocation policy in 2002 has led to an increase in the number of simultaneous liver kidney (SLK) transplantation. Since kidney function recovery following liver transplantation is difficult to predict, allocation of the kidney for SLK transplantation thus far has not been based on much rationale and evidence. Lack of OPTN policy towards SLK organ allocation has resulted in great variations among transplant centers regarding SLK transplantation. Increasing use of kidneys towards SLK transplantation diverts deceased donor kidneys away from candidates awaiting kidney-alone transplantation. Recently OPTN/United Network of Organ Sharing has implemented medical eligibility criteria for adult SLK transplantation which also includes a concept of safety net. Implementation of the new policy is a move in a positive direction, providing consistency in our practice and evidence-based guidelines in selecting candidates for SLK transplantation. This policy needs to be monitored prospectively and modified based on new data that will emerge over time. This review outlines the literature on SLK transplantation and efforts towards developing rational policy on SLK organ allocation.

Effect of transplant center volume on post-transplant survival in patients listed for simultaneous liver and kidney transplantation

AIM

To examine the effect of center size on survival differences between simultaneous liver kidney transplantation (SLKT) and liver transplantation alone (LTA) in SLKT-listed patients.

METHODS

The United Network of Organ Sharing database was queried for patients ≥ 18 years of age listed for SLKT between February 2002 and December 2015. Post-transplant survival was evaluated using stratified Cox regression with interaction between transplant type (LTA vs SLKT) and center volume.

RESULTS

During the study period, 393 of 4580 patients (9%) listed for SLKT underwent a LTA. Overall mortality was higher among LTA recipients (180/393, 46%) than SLKT recipients (1107/4187, 26%). The Cox model predicted a significant survival disadvantage for patients receiving LTA vs SLKT [hazard ratio, hazard ratio (HR) = 2.85; 95%CI: 2.21, 3.66; P < 0.001] in centers performing 30 SLKT over the study period. This disadvantage was modestly attenuated as center SLKT volume increased, with a 3% reduction (HR = 0.97; 95%CI: 0.95, 0.99; P = 0.010) for every 10 SLKs performed.

CONCLUSION

In conclusion, LTA is associated with increased mortality among patients listed for SLKT. This difference is modestly attenuated at more experienced centers and may explain inconsistencies between smaller-center and larger registry-wide studies comparing SLKT and LTA outcomes.

Simultaneous Liver-Kidney Transplantation: Impact on Liver Transplant Patients and the Kidney Transplant Waiting List

Purpose

The number of simultaneous liver-kidney transplants (SLKT) performed in the USA has been rising. The Organ Procurement and Transplantation Network implemented a new policy governing SLKT that specifies eligibility criteria for candidates to receive a kidney with a liver, and creates a kidney waitlist “safety net” for liver recipients with persistent renal failure after transplant. This review explores potential impacts for liver patients and the kidney waitlist.

Recent Findings

Factors that have contributed to the rise in SLKT including Model for End-stage Liver Disease (MELD)-based allocation, regional sharing for high MELD candidates, and the rising incidence of non-alcoholic steatohepatitis will continue to increase the number of liver transplant candidates with concurrent renal insufficiency. The effect of center behavior based on the new policy is harder to predict, given wide historic variability in SLKT practice.

Summary

Continued increase in combined liver/kidney failure is likely, and SLKT and kidney after liver transplant may both increase. Impact of the new policy should be carefully monitored, but influences beyond the policy need to be accounted for.