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Tanaka T, Lentine KL, Shi Q, Vander Weg M, Axelrod DA. Differential Impact of the UNOS Simultaneous Liver-kidney Transplant Policy Change Among Patients With Sustained Acute Kidney Injury. Transplantation 2024; 108:724-731. [PMID: 37677960 DOI: 10.1097/tp.0000000000004774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Simultaneous liver-kidney transplant (SLK) allocation policy in the United States was revised in August 2017, reducing access for liver transplant candidates with sustained acute kidney injury (sAKI) and potentially adversely impacting vulnerable populations whose true renal function is overestimated by commonly used estimation equations. METHODS We examined national transplant registry data containing information for all liver transplant recipients from June 2013 to December 2021 to assess the impact of this policy change using instrumental variable estimation based on date of listing. RESULTS Posttransplant survival was compared for propensity-matched patients with sAKI who were only eligible for liver transplant alone (LTA_post; n = 638) after the policy change but would have been SLK-eligible before August 2017, with similar patients who were previously able to receive an SLK (SLK; n = 319). Overall posttransplant patient survival was similar at 3 y (81% versus 80%; P = 0.9). However, receiving an SLK versus LTA increased survival among African Americans (87% versus 61% at 3 y; P = 0.029). A trend toward survival benefit from SLK versus LTA, especially later in the follow-up period, was observed in recipients ≥ age 60 (3-y survival: 84% versus 76%; P = 0.2) and women (86% versus 80%; P = 0.2). CONCLUSIONS The 2017 United Network for Organ Sharing SLK Allocation Policy was associated with reduced survival of African Americans with end-stage liver disease and sAKI and, potentially, older patients and women. Our study suggested the use of race-neutral estimation of renal function would ameliorate racial disparities in the SLK arena; however, further studies are needed to reduce disparity in posttransplant outcomes among patients with liver and kidney failure.
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Affiliation(s)
- Tomohiro Tanaka
- Division of Gastroenterology and Hepatology, University of Iowa Carver College of Medicine, Iowa City, IA
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA
- University of Iowa Carver College of Medicine, Iowa City, IA
| | - Krista L Lentine
- Saint Louis University Transplant Center, SSM-Saint Louis University Hospital, St. Louis, MO
| | - Qianyi Shi
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA
- University of Iowa Carver College of Medicine, Iowa City, IA
| | - Mark Vander Weg
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, IA
| | - David A Axelrod
- Division of Transplantation and Hepatobiliary Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
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2
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Schold JD, Mohan S, Jackson WE, Stites E, Burton JR, Bababekov YJ, Saben JL, Pomposelli JJ, Pomfret EA, Kaplan B. Differential in Kidney Graft Years on the Basis of Solitary Kidney, Simultaneous Liver-Kidney, and Kidney-after-Liver Transplants. Clin J Am Soc Nephrol 2024; 19:364-373. [PMID: 37962880 PMCID: PMC10937020 DOI: 10.2215/cjn.0000000000000353] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/07/2023] [Indexed: 11/15/2023]
Abstract
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.
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Affiliation(s)
- Jesse D. Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Whitney E. Jackson
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Erik Stites
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - James R. Burton
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Yanik J. Bababekov
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jessica L. Saben
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - James J. Pomposelli
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Elizabeth A. Pomfret
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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3
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Fraser M, Agdamag AC, Riad S, Nzemenoh BN, Jackson S, Money J, Knoper R, Martin CM, Alexy T. Survival After Simultaneous Heart-kidney Transplant in Recipients With a Durable LVAD and Chronic Kidney Disease: Effect of the 2018 Heart Allocation Policy Change. Transplantation 2024; 108:524-529. [PMID: 37677944 DOI: 10.1097/tp.0000000000004781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Heart transplantation remains the most definitive therapy for qualified candidates with end-stage heart failure. Concomitant kidney disease is common in this population prompting an increase in simultaneous heart-kidney (SHK) transplantation in recent years. The goal of our study was to explore the effects of the 2018 heart allocation policy (HAP) change on candidate listing characteristics and compare survival rates at 1 y in patients that were supported with a left ventricular assist device (LVAD) pretransplant and underwent SHK or heart alone transplant (HAT). METHODS We used data from the Scientific Registry of Transplant Recipients and identified all adults who underwent primary SHK or HAT between January 2010 and March 2022. Recipients supported with a durable LVAD and estimated glomerular filtration rate <60 mL/min/1.73 m 2 were selected (n = 309 SHK; 217 pre- and 92 post-HAP and n = 3,324 HAT; 2738 pre- and 586 post-HAP). RESULTS Difference in survival at 1 y did not reach statistical significance. Comparing the 1-y survival of SHK and HAT recipients who were bridged with LVAD pre-HAP, we found no significant difference ( P = 0.694). Adjusting for the same covariates in a multivariable model did not affect the results (SHK versus HAT hazard ratio 0.84 [0.51, 1.37]; P = 0.48). In contrast, SHK recipients supported with an LVAD who were listed and transplanted post-HAP change had significantly lower 1-y survival, when compared with HAT ( P = 0.037). CONCLUSIONS Our findings suggest that the HAP change had a potentially negative impact on the survival of select patients undergoing SHK transplant. Further research is warranted in this area.
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Affiliation(s)
- Meg Fraser
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Arianne C Agdamag
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Samy Riad
- Division of Nephrology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | | | - Scott Jackson
- Analytics Consulting Services, MHealth Fairview, Minneapolis, MN
| | - Joel Money
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Ryan Knoper
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Cindy M Martin
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
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Husain SA, Hippen B, Singh N, Parsons RF, Bloom RD, Anand PM, Lentine KL. Right-Sizing Multiorgan Allocation Involving Kidneys. Clin J Am Soc Nephrol 2023; 18:1503-1506. [PMID: 37379084 PMCID: PMC10637446 DOI: 10.2215/cjn.0000000000000242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/21/2023] [Indexed: 06/29/2023]
Affiliation(s)
- S. Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Benjamin Hippen
- Transplant Medicine and Emerging Capabilities, Fresenius Medical Care, Charlotte, North Carolina
| | - Neeraj Singh
- John C McDonald Regional Transplant Center, Willis Knighton Health System, Shreveport, Louisiana
| | - Ronald F. Parsons
- Department of Surgery, Emory Transplant Center, Emory University School of Medicine, Atlanta, Georgia
| | - Roy D. Bloom
- Renal Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Prince Mohan Anand
- Division of Nephrology, Medical University of South Carolina, Lancaster, South Carolina
| | - Krista L. Lentine
- Center for Abdominal Transplantation, SSM-Saint Louis University Hospital, Saint Louis, Missouri
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5
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Chen Q, Malas J, Roach A, Kumaresan A, Thomas J, Bowdish ME, Chikwe J, Zaffiri L, Rampolla RE, Catarino P, Megna D. Simultaneous Lung-Kidney Transplantation in the United States. Ann Thorac Surg 2023; 116:1063-1070. [PMID: 37356520 PMCID: PMC10672664 DOI: 10.1016/j.athoracsur.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/22/2023] [Accepted: 06/06/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Simultaneous lung-kidney transplantation is rarely performed. Contemporary national practice trends and outcomes are unclear. METHODS From the United Network for Organ Sharing database, we identified 108 lung-kidney transplant recipients (2005-2022). They were compared with isolated lung recipients with pretransplantation dialysis or estimated glomerular filtration rate (eGFR) ≤30 mL/min per 1.73 m2 (n = 372) and isolated non-dialysis-dependent lung recipients with 30 < eGFR < 50 mL/min per 1.73 m2 (n = 1416), respectively. Lung-kidney recipients were also compared with recipients of the contralateral kidney from the same donors (n = 90). RESULTS Lung-kidney transplantation was performed by 36 centers, with increasing annual volume (1 in 2005, 16 in 2022; P < .01). Forty percent (44/108) of lung-kidney recipients received pretransplantation dialysis, and of those without pretransplantation dialysis, median eGFR was 30.7 mL/min per 1.73 m2. Lung-kidney recipients had improved survival compared with isolated lung recipients with eGFR ≤30 mL/min per 1.73 m2 or pretransplantation dialysis (adjusted hazard ratio, 0.59; 95% CI, 0.38-0.92). However, no survival benefit was observed when lung-kidney recipients were compared with isolated lung recipients with 30 < eGFR < 50 mL/min per 1.73 m2 and no pretransplantation dialysis (adjusted hazard ratio, 0.88; 95% CI, 0.55-1.41). Compared with isolated kidney recipients using the contralateral kidney from the same donors, lung-kidney recipients had a higher risk of kidney allograft loss (adjusted hazard ratio, 3.27; 95% CI, 1.22-8.78), a difference largely accounted for by patient death with a functioning kidney allograft. CONCLUSIONS Recipients of lung-kidney transplants had improved survival compared with isolated lung recipients with eGFR ≤30 mL/min per 1.73 m2 or pretransplantation dialysis. However, lung-kidney recipients had a higher rate of kidney allograft loss than recipients of the contralateral kidney allograft from the same donors.
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Affiliation(s)
- Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jad Malas
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Amy Roach
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Abirami Kumaresan
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jason Thomas
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael E Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Lorenzo Zaffiri
- Department of Pulmonary and Critical Care Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Reinaldo E Rampolla
- Department of Pulmonary and Critical Care Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Pedro Catarino
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dominick Megna
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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6
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Chen Q, Malas J, Gianaris K, Esmailian G, Emerson D, Megna D, Catarino P, Czer L, Bowdish ME, Chikwe J, Patel J, Kobashigawa J, Esmailian F. Simultaneous heart-kidney transplant in patients with borderline estimated glomerular filtration rate without dialysis dependency. Clin Transplant 2023; 37:e14986. [PMID: 37026791 PMCID: PMC11144457 DOI: 10.1111/ctr.14986] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/07/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Appropriate patient selection for simultaneous heart-kidney transplantation (sHK) in patients with moderate renal dysfunction remains challenging. METHODS From the United Network for Organ Sharing database (2003-2020), we identified 5678 adults with an estimated pre-transplant glomerular filtration rate (eGFR) between 30 and 45 mL/min/1.73 m2 and no pre-transplant dialysis. Patients undergoing sHK (n = 293) were compared with those undergoing heart transplantation alone (n = 5385) using 1:3 propensity score matching. RESULTS The sHK utilization rate increased from 1.8% in 2003 to 12.2% in 2020 (p < .001). After matching, 1 and 5-year survival was 87.7% (95% confidence interval [CI] 83.3-91.0) and 80.0% (95% CI 74.2-84.6) after sHK, and 87.3% (95% CI 85.2-89.1) and 71.8% (95% CI 68.4-74.9) after heart transplant alone (p = .04). In the subgroup analysis, sHK was associated with a 5-year survival benefit only in patients with 30 < eGFR ≤ 35 mL/min/1.73 m2 (p = .05) but not in those with 35 < eGFR < 45 mL/min/1.73 m2 (p = .45). Patients who underwent heart transplants alone also had a higher incidence of becoming chronic dialysis-dependent after transplant within 5-year follow-up (10.2%, 95% CI 8.0-12.6 vs. 3.8%, 95% CI 1.7-7.1, p = .004). The 5-year incidence of subsequent kidney waitlisting and transplants after heart transplants alone was 5.6% and 1.9%, respectively. CONCLUSION Among propensity-matched patients without pre-transplant dialysis, compared to heart transplants alone, sHK had improved 5-year survival in those with 30 < eGFR ≤ 35 but not in those with 35 < eGFR < 45 mL/min/1.73 m2 . One-year survival was similar irrespective of eGFR. Receiving a kidney after a heart transplant alone is rare under the current allocation system.
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Affiliation(s)
- Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jad Malas
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Kevin Gianaris
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gabriel Esmailian
- The George Washington School of Medicine and Health Sciences, Washington, D.C., USA
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dominick Megna
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Pedro Catarino
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lawrence Czer
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael E. Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jignesh Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jon Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Fardad Esmailian
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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7
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Agdamag AC, Riad S, Maharaj V, Jackson S, Fraser M, Charpentier V, Nzemenoh B, Martin CM, Alexy T. Temporary Mechanical Circulatory Support Use and Clinical Outcomes of Simultaneous Heart/Kidney Transplant Recipients in the Pre- and Post-heart Allocation Policy Change Eras. Transplantation 2023; 107:1605-1614. [PMID: 36706061 DOI: 10.1097/tp.0000000000004518] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The use of temporary mechanical circulatory support (tMCS) devices (intra-aortic balloon pump; Impella 2.5, CP, 5.0; venoarterial extracorporeal membrane oxygenation) increased significantly across the United States for heart transplant candidates after the allocation policy change. Whether this practice change also affected simultaneous heart-kidney (SHK) candidates and recipient survival is understudied. METHODS We used the Scientific Registry of Transplant Recipients database to identify adult SHK recipients between January 2010 and March 2022. The population was stratified into pre- and post-heart allocation change cohorts. Kaplan-Meier curves were generated to compare 1-y survival rates. A Cox proportional hazards model was used to investigate the effect of allocation period on patient survival. Recipient outcomes bridged with eligible tMCS devices were compared in the post-heart allocation era. In a separate analysis, SHK waitlist mortality was evaluated between the allocation eras. RESULTS A total of 1548 SHK recipients were identified, and 1102 were included in the final cohort (534 pre-allocation and 568 post-allocation change). tMCS utilization increased from 17.9% to 51.6% after the allocation change, with venoarterial extracorporeal membrane oxygenation use rising most significantly. However, 1-y post-SHK survival remained unchanged in the full cohort (log-rank P = 0.154) and those supported with any of the eligible tMCS devices. In a separate analysis (using a larger cohort of all SHK listings), SHK waitlist mortality at 1 y was significantly lower in the current allocation era ( P = 0.002). CONCLUSIONS Despite the remarkable increase in tMCS use in SHK candidates after the heart allocation change, 1 y posttransplant survival remained unchanged. Further studies with larger cohorts and longer follow-ups are needed to confirm these findings.
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Affiliation(s)
- Arianne C Agdamag
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Samy Riad
- Division of Nephrology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Valmiki Maharaj
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Scott Jackson
- Complex Care Analytics, Fairview Health Services, Minneapolis, MN
| | - Meg Fraser
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | | | - Bellony Nzemenoh
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Cindy M Martin
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
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Gonzalez SA, Farfan Ruiz AC, Ibrahim RM, Wadei HM. Essentials of Liver Transplantation in the Setting of Acute Kidney Injury and Chronic Kidney Disease. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:356-367. [PMID: 37657882 DOI: 10.1053/j.akdh.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 09/03/2023]
Abstract
Kidney dysfunction is common among liver transplant candidates with decompensated cirrhosis and has a major impact on pre- and post-liver transplant survival. Updated definitions of acute kidney injury and criteria for the diagnosis of hepatorenal syndrome allow for early recognition and intervention, including early initiation of vasoconstrictor therapy for hepatorenal syndrome. The rise of the metabolic syndrome and nonalcoholic fatty liver disease as a cause of cirrhosis has coincided with an increase in intrinsic chronic kidney disease recognized in transplant candidates and recipients. Ultimately, the ability to accurately assess kidney function and associated risk is essential to decision-making in the context of transplantation, including selection of candidates for simultaneous liver and kidney transplantation.
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Affiliation(s)
- Stevan A Gonzalez
- Division of Hepatology, Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White All Saints Medical Center Fort Worth and Baylor University Medical Center Dallas, TX; Department of Medicine, Burnett School of Medicine at TCU, Fort Worth, TX.
| | - Ana Cecilia Farfan Ruiz
- Division of Transplant Nephrology, Department of Transplant, Mayo Clinic College of Medicine and Science, Jacksonville, FL
| | - Ramez M Ibrahim
- Division of Transplant Nephrology, Department of Transplant, Mayo Clinic College of Medicine and Science, Jacksonville, FL
| | - Hani M Wadei
- Division of Transplant Nephrology, Department of Transplant, Mayo Clinic College of Medicine and Science, Jacksonville, FL
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Ahsan SA, El Nihum LI, Arunachalam P, Manian N, Al Abri Q, Guha A. Current considerations for heart-kidney transplantation. FRONTIERS IN TRANSPLANTATION 2022; 1:1022780. [PMID: 38994391 PMCID: PMC11235302 DOI: 10.3389/frtra.2022.1022780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/28/2022] [Indexed: 07/13/2024]
Abstract
Cardiorenal syndrome is a complex syndrome characterized by dysfunction of the heart and kidneys in an interdependent fashion and is further divided into different subtypes based on primary organ dysfunction. Simultaneous Heart-Kidney transplantation is the treatment of choice for end-stage irreversible dysfunction of both organs, however it may be avoided with determination of cardiorenal subtype and management of primary organ dysfunction. This article discusses types of cardiorenal syndrome, indications and concerns regarding the use of simultaneous heart-kidney transplantation, and outlines algorithms for determination of need for dual vs. single organ transplantation.
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Affiliation(s)
- Syed Adeel Ahsan
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
| | - Lamees I. El Nihum
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
- Texas A&M College of Medicine, Bryan, TX, United States
| | - Priya Arunachalam
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
- Texas A&M College of Medicine, Bryan, TX, United States
| | - Nina Manian
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
- Texas A&M College of Medicine, Bryan, TX, United States
| | - Qasim Al Abri
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
| | - Ashrith Guha
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
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10
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Severely Reduced Kidney Function Assessed by a Single eGFR Determination at the Time of an Isolated Heart Transplant Does Not Predict Inevitable Posttransplant ESKD. Transplantation 2022; 107:981-987. [PMID: 36223634 DOI: 10.1097/tp.0000000000004350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Consensus guidelines advise simultaneous heart kidney transplantation (SHK) in heart candidates with an estimated glomerular filtration rate (eGFR) of <30 mL/min/1.73 m 2 . We hypothesize that a significant fraction of such patients would not need an SHK, even though a graded increase in mortality and end-stage kidney disease (ESKD) would be seen with decrements in eGFR. METHODS United Network of Organ Sharing data for isolated heart transplants between 2000 and 2020 were divided into two groups based on eGFR at transplant (≤20 mL/min/1.73 m 2 and 21-29 mL/min/1.73 m 2 ). The primary outcome was mortality and secondary outcome was ESKD posttransplant. Cox regression and cumulative incidence competing risk methods were used to compare risk of mortality and ESKD. RESULTS There was no difference in mortality (adjusted hazard ratio [aHR] 0.82 [95% confidence interval, CI: 0.60-1.11, P = 0.21]) or ESKD (aHR 1.01 [95% CI: 0.49-2.09, P = 0.96]) between the two groups (≤20 versus 21-29). The overall incidence of ESKD for the entire cohort at 1, 5, and 10 y were 1.5%, 9.5%, and 20%. CONCLUSIONS Although risk of ESKD is highest in heart candidates with an eGFR <30 mL/min/1.73 m 2 , <10% of patients reach ESKD within 5 y' and most will recover significant renal function posttransplant. More refined selection criteria are required to identify candidates for SHK.
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11
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Batra RK, Ariyamuthu VK, MacConmara MP, Gupta G, Gungor AB, Tanriover B. Outcomes of Simultaneous Liver-Kidney Transplantation Using Kidneys of Deceased Donors With Acute Kidney Injury. Liver Transpl 2022; 28:983-997. [PMID: 35006615 DOI: 10.1002/lt.26406] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 12/24/2021] [Accepted: 01/07/2022] [Indexed: 01/13/2023]
Abstract
Outcomes from simultaneous liver-kidney transplantation (SLKT) when using kidneys from donors with acute kidney injury (AKI) have not been studied. We studied 5344 SLKTs between May 1, 2007, and December 31, 2019, by using Organ Procurement and Transplantation Network registry data supplemented with United Network for Organ Sharing-DonorNet data. Designating a donor as having AKI required by definition that the following criteria were met: (1) the donor's condition aligned with the Kidney Disease: Improving Global Outcomes (KDIGO) international consensus guidelines and the terminal serum creatinine (Scr) level was ≥1.5 times the minimum Scr level for deceased donors before organ recovery and (2) the terminal Scr level was ≥1.5 mg/dL (a clinically meaningful and intuitive Scr threshold for defining AKI for transplant providers). The primary outcomes were liver transplant all-cause graft failure (ACGF; defined as graft failures and deaths) and kidney transplant death-censored graft failure (DCGF) at 1 year after transplant. The donors with AKI were young, had good organ quality, and had a short cold ischemia time. In the study cohort, 4482 donors had no AKI, whereas 862 had AKI (KDIGO AKI stages: 1, n = 521; 2, n = 202; and 3, n = 138). In the group with AKI and the group with no AKI, respectively, liver ACGF at 1 year (11.1% versus 12.9% [P = 0.13]; hazard ratio [HR], 1.20; 95% confidence interval [CI], 0.97-1.49) and kidney DCGF at 1 year (4.6% versus 5.7% [P = 0.18]; HR, 1.27; 95% CI, 0.95-1.70) did not differ in the full multivariable Cox proportional hazard models. Selected kidneys from deceased donors with AKI can be considered for SLKT.
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Affiliation(s)
- Ramesh K Batra
- Department of Surgery, School of Medicine, Yale University, New Haven, CT
| | | | | | - Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA
| | - Ahmet B Gungor
- Division of Nephrology, Banner University Medical Group, Tucson, AZ
| | - Bekir Tanriover
- Division of Nephrology, College of Medicine, University of Arizona, Tucson, AZ
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12
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Kumar A, Bonnell LN, Eberlein M, Thomas CP. The U-shaped association of post-lung transplant mortality with pre-transplant eGFR underscores possible limitations of creatinine-based estimation equations for risk stratification. J Heart Lung Transplant 2022; 41:1277-1284. [DOI: 10.1016/j.healun.2022.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 05/10/2022] [Accepted: 05/30/2022] [Indexed: 12/01/2022] Open
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13
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Shaw BI, Samoylova ML, Barbas AS, Cheng XS, Lu Y, McElroy LM, Sanoff S. Center variations in patient selection for simultaneous heart-kidney transplantation. Clin Transplant 2022; 36:e14619. [PMID: 35175664 PMCID: PMC10067274 DOI: 10.1111/ctr.14619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/20/2022] [Accepted: 02/12/2022] [Indexed: 11/28/2022]
Abstract
There are no established regulations governing patient selection for simultaneous heart-kidney (SHK) transplantation, creating the potential for significant center-level variations in clinical practice. METHODS Using the United Network for Organ Sharing (UNOS) Standard Transplant Analysis and Research (STAR) file, we examined practice trends and variations in patient selection for SHK at the center level between January 1, 2004 and March 31, 2019. RESULTS Overall, SHK is becoming more common with most centers performing heart transplants also performing SHK. Among patients who underwent heart transplant who were receiving dialysis, the rate of SHK varied from 22% to 86% at the center level. Among patients not on dialysis, the median estimated glomerular filtration rate (eGFR) of patients receiving SHK varied between 19 and 59 mL/min/1.73 m2 . When adjusting for other factors, the odds of SHK varied 57-fold between the highest and lowest SHK performing centers. CONCLUSION Variation in SHK at the center level suggests the need for national guidelines around the selection of patients for SHK.
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Affiliation(s)
- Brian I Shaw
- Department of Surgery, Duke, University, Durham, North Carolina, USA
| | - Marya L Samoylova
- Department of Surgery, Duke, University, Durham, North Carolina, USA
| | - Andrew S Barbas
- Department of Surgery, Duke, University, Durham, North Carolina, USA
| | - Xingxing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University, Palo Alto, California, USA
| | - Yee Lu
- Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa M McElroy
- Department of Surgery, Duke, University, Durham, North Carolina, USA
| | - Scott Sanoff
- Department of Medicine, Division of Nephrology, Duke University, Durham, North Carolina, USA
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14
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Wayda B, Cheng XS, Goldhaber-Fiebert JD, Khush KK. Optimal patient selection for simultaneous heart-kidney transplant: A modified cost-effectiveness analysis. Am J Transplant 2022; 22:1158-1168. [PMID: 34741786 PMCID: PMC8983443 DOI: 10.1111/ajt.16888] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/12/2021] [Accepted: 10/31/2021] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Brian Wayda
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California
| | - Xingxing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Jeremy D Goldhaber-Fiebert
- Center of Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California
| | - Kiran K Khush
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine, Stanford, California
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15
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Multi-Organ Allocation: Medical and Ethical Considerations. CURRENT TRANSPLANTATION REPORTS 2022. [DOI: 10.1007/s40472-022-00354-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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16
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Wilk AR, Booker SE, Stewart DE, Wiseman A, Gauntt K, Mulligan D, Formica RN. Developing simultaneous liver-kidney transplant medical eligibility criteria while providing a safety net: A 2-year review of the OPTN's allocation policy. Am J Transplant 2021; 21:3593-3607. [PMID: 34254434 DOI: 10.1111/ajt.16761] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 01/25/2023]
Abstract
The OPTN's simultaneous liver-kidney (SLK) allocation policy, implemented August 10, 2017, established medical eligibility criteria for adult SLK candidates and created Safety Net kidney allocation priority for liver-alone recipients with new/continued renal impairment. OPTN SLK and kidney after liver (KAL) data were analyzed (registrations as of December 31, 2019, transplants pre-policy [March 20, 2015-August 9, 2017] vs. post-policy [August 10, 2017-December 31, 2019]). Ninety-four percent of SLK registrations met eligibility criteria (99% CKD: 50% dialysis, 50% eGFR). SLK transplant volume decreased from a record 740 (2017) to 676 (2018, -9%), with a subsequent increase to 728 (2019, 1.6% below 2017 volume). For KAL listings within 1 year of liver transplant, waitlist mortality rates declined post-policy versus pre-policy (27 [95% CI = 20.6-34.7] vs. 16 [11.7-20.5]) while transplant rates increased fourfold (46 [32.2-60.0] vs. 197 [171.6-224.7]). There were 234 KAL transplants post-policy (94% Safety Net priority eligible), and no significant difference in 1-year patient/graft survival vs. kidney-alone (patient: 95.9% KAL, 97.0% kidney-alone [p = .39]; graft: 94.2% KAL, 94.6% kidney-alone [p = .81]). From pre- to post-policy, the proportion of all deceased donor kidney and liver transplants that were SLK decreased (kidney: 5.1% to 4.3%; liver: 9.7% to 8.7%). SLK policy implementation interrupted the longstanding rise in SLK transplants, while Safety Net priority directed kidneys to liver recipients in need with thus far minimal impact to posttransplant outcomes.
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Affiliation(s)
- Amber R Wilk
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Sarah E Booker
- United Network for Organ Sharing, Richmond, Virginia, USA
| | | | | | - Katrina Gauntt
- United Network for Organ Sharing, Richmond, Virginia, USA
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17
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Westphal SG, Langewisch ED, Miles CD. Current State of Multiorgan Transplantation and Implications for Future Practice and Policy. Adv Chronic Kidney Dis 2021; 28:561-569. [PMID: 35367024 DOI: 10.1053/j.ackd.2021.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/17/2021] [Accepted: 09/28/2021] [Indexed: 12/07/2022]
Abstract
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.
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18
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Truong TT, Nadim MK. Is Prioritization of Kidney Allografts to Combined Liver-Kidney Recipients Appropriate? PRO. KIDNEY360 2021; 3:993-995. [PMID: 35845321 PMCID: PMC9255876 DOI: 10.34067/kid.0001632021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/14/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Tiffany T. Truong
- Division of Nephrology and Hypertension, University of Southern California, Los Angeles, California
| | - Mitra K. Nadim
- Division of Nephrology and Hypertension, University of Southern California, Los Angeles, California
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19
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Cheng XS. Is Prioritization of Kidney Allografts to Combined Liver-Kidney Recipients Appropriate? CON. KIDNEY360 2021; 3:996-998. [PMID: 35845329 PMCID: PMC9255887 DOI: 10.34067/kid.0002082021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/09/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Xingxing S. Cheng
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
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20
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Sharma P, Sui Z, Zhang M, Magee JC, Barman P, Patel Y, Schluger A, Walter K, Biggins SW, Cullaro G, Wong R, Lai JC, Jo J, Sinha J, VanWagner L, Verna EC. Renal Outcomes After Simultaneous Liver-Kidney Transplantation: Results from the US Multicenter Simultaneous Liver-Kidney Transplantation Consortium. Liver Transpl 2021; 27:1144-1153. [PMID: 33641218 PMCID: PMC8823286 DOI: 10.1002/lt.26032] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/29/2020] [Accepted: 01/26/2021] [Indexed: 12/19/2022]
Abstract
Simultaneous liver-kidney transplantation (SLKT) is increasingly common in the United States. However, little is known about the renal-related outcomes following SLKT, which are essential to maximize the health of these allografts. We examined the factors impacting renal function following SLKT. This is an observational multicenter cohort study from the US Multicenter SLKT Consortium consisting of recipients of SLKT aged ≥18 years of transplantations performed between February 2002 and June 2017 at 6 large US centers in 6 different United Network for Organ Sharing regions. The primary outcome was incident post-SLKT stage 4-5 chronic kidney disease (CKD) defined as <30 mL/minute/1.73 m2 or listing for kidney transplant. The median age of the recipients (n = 570) was 58 years (interquartile range, 51-64 years), and 37% were women, 76% were White, 33% had hepatitis C virus infection, 20% had nonalcoholic steatohepatitis (NASH), and 23% had alcohol-related liver disease; 68% developed ≥ stage 3 CKD at the end of follow-up. The 1-year, 3-year, and 5-year incidence rates of post-SLKT stage 4-5 CKD were 10%, 12%, and 16%, respectively. Pre-SLKT diabetes mellitus (hazard ratio [HR], 1.45; 95% CI, 1.00-2.15), NASH (HR, 1.58; 95% CI, 1.01-2.45), and delayed kidney graft function (HR, 1.72; 95% CI, 1.10-2.71) were the recipient factors independently associated with high risk, whereas the use of tacrolimus (HR, 0.44; 95% CI, 0.22-0.89) reduced the risk. Women (β = -6.22 ± 2.16 mL/minute/1.73 m2 ; P = 0.004), NASH (β = -7.27 ± 3.27 mL/minute/1.73 m2 ; P = 0.027), and delayed kidney graft function (β = -7.25 ± 2.26 mL/minute/1.73 m2 ; P = 0.007) were independently associated with low estimated glomerular filtration rate at last follow-up. Stage 4-5 CKD is common after SLKT. There remains an unmet need for personalized renal protective strategies, specifically stratified by sex, diabetes mellitus, and liver disease, to preserve renal function among SLKT recipients.
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Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI
| | - Zhiyu Sui
- Department of Biostatistics, School of Public Health, Michigan Medicine, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, Michigan Medicine, Ann Arbor, MI
| | - John C. Magee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Pranab Barman
- Division of Gastroenterology and Hepatology, University of California, San Diego, CA
| | - Yuval Patel
- Division of Gastroenterology, Duke University, Durham, NC
| | - Aaron Schluger
- Section of Internal Medicine, Westchester Medical Center, Westchester, NY
| | - Kara Walter
- Division of Digestive Diseases, University of California, Los Angeles, CA
| | - Scott W. Biggins
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, WA
| | - Giuseppe Cullaro
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY
| | - Randi Wong
- Division of Gastroenterology and Hepatology, University of California, San Francisco, CA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, CA
| | - Jennifer Jo
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | - Jasmine Sinha
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | - Lisa VanWagner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY
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21
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Samoylova ML, Wegermann K, Shaw BI, Kesseli SJ, Au S, Park C, Halpern SE, Sanoff S, Barbas AS, Patel YA, Sudan DL, Berg C, McElroy LM. The Impact of the 2017 Kidney Allocation Policy Change on Simultaneous Liver-Kidney Utilization and Outcomes. Liver Transpl 2021; 27:1106-1115. [PMID: 33733560 PMCID: PMC8380035 DOI: 10.1002/lt.26053] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/10/2021] [Accepted: 03/08/2021] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Mariya L. Samoylova
- Department of Surgery, Division of Gastroenterology, Duke University Hospital, Durham, NC
| | - Kara Wegermann
- Department of Medicine, Division of Gastroenterology, Duke University Hospital, Durham, NC
| | - Brian I. Shaw
- Department of Surgery, Division of Gastroenterology, Duke University Hospital, Durham, NC
| | - Samuel J. Kesseli
- Department of Surgery, Division of Gastroenterology, Duke University Hospital, Durham, NC
| | - Sandra Au
- Duke University School of Medicine, Durham, NC
| | | | | | - Scott Sanoff
- Division of Nephrology, Department of Medicine, Duke Unviersity Hospital, Durham, NC
| | - Andrew S. Barbas
- Department of Surgery, Division of Gastroenterology, Duke University Hospital, Durham, NC
| | - Yuval A. Patel
- Division of Hepatology, Department of Medicine, Duke Unviersity Hospital, Durham, NC
| | - Debra L. Sudan
- Department of Surgery, Division of Gastroenterology, Duke University Hospital, Durham, NC
| | - Carl Berg
- Division of Nephrology, Department of Medicine, Duke Unviersity Hospital, Durham, NC
| | - Lisa M. McElroy
- Department of Surgery, Division of Gastroenterology, Duke University Hospital, Durham, NC
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22
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Nilles KM, Levitsky J. Current and Evolving Indications for Simultaneous Liver Kidney Transplantation. Semin Liver Dis 2021; 41:308-320. [PMID: 34130337 DOI: 10.1055/s-0041-1729969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This review will discuss the etiologies of kidney disease in liver transplant candidates, provide a historical background of the prior evolution of simultaneous liver-kidney (SLK) transplant indications, discuss the current indications for SLK including Organ Procurement and Transplantation Network policies and Model for End Stage Liver Disease exception points, as well as provide an overview of the safety net kidney transplant policy. Finally, the authors explore unanswered questions and future research needed in SLK transplantation.
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Affiliation(s)
- Kathy M Nilles
- Division of Gastroenterology and Hepatology, Department of Medicine, MedStar Georgetown Transplant Institute, Georgetown University School of Medicine, Washington, District of Columbia
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Department of Medicine, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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23
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Cheng XS, Reese PP. Incorporating kidney-related multi-organ transplants into the kidney allocation sequence. Am J Transplant 2021; 21:2614-2615. [PMID: 33594713 DOI: 10.1111/ajt.16542] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/19/2021] [Accepted: 02/11/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, Philadelphia, Pennsylvania.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, Philadelphia, Pennsylvania
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24
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Shaw BI, Samoylova ML, Sanoff S, Barbas AS, Sudan DL, Boulware LE, McElroy LM. Need for improvements in simultaneous heart-kidney allocation: The limitation of pretransplant glomerular filtration rate. Am J Transplant 2021; 21:2468-2478. [PMID: 33350052 PMCID: PMC8412966 DOI: 10.1111/ajt.16466] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 01/25/2023]
Abstract
The incidence of simultaneous heart-kidney transplant (SHK) has increased markedly in the last 15 years. There are no universally agreed upon indications for SHK vs. heart alone (HA) transplant, and center evaluation processes vary widely. We utilized Scientific Registry of Transplant Recipients data from 2003 to 2017 to quantify changes in the practice of SHK, examine the survival of SHK vs. HA, and identify patients with marginal benefit from SHK. We used Kaplan-Meier curves and Cox proportional hazards to assess differences in survival. The incidence of SHK increased more than fourfold between 2003 and 2017 from 1.6% to 6.6% of total hearts transplanted, while the proportion of dialysis-dependent patients undergoing SHK has remained constant. SHK was associated with increased survival in dialysis-dependent patients (Median Survival SHK: 12.6 vs. HA: 7.1 years p < .0001) but not with nondialysis-dependent patients (Median Survival SHK: 12.5 vs. HA 12.3, p = .24). The marginal effect of SHK in decreasing the hazard of death diminished with increasing eGFR. Delayed graft function occurred in 26% of SHK recipients. Posttransplant chronic dialysis was similar for both operations (6.4% of HA and 6.0% of SHK). Further study is needed to define patients who benefit from SHK.
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Affiliation(s)
- Brian I Shaw
- Division of Abdominal Transplantation, Department of Surgery, Duke University, Durham, NC
| | - Mariya L Samoylova
- Division of Abdominal Transplantation, Department of Surgery, Duke University, Durham, NC
| | - Scott Sanoff
- Division of Nephrology, Department of Medicine, Duke University, Durham, NC
| | - Andrew S Barbas
- Division of Abdominal Transplantation, Department of Surgery, Duke University, Durham, NC
| | - Debra L Sudan
- Division of Abdominal Transplantation, Department of Surgery, Duke University, Durham, NC
| | - L. Ebony Boulware
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - Lisa M McElroy
- Division of Abdominal Transplantation, Department of Surgery, Duke University, Durham, NC
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25
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Shah L, Dube G, Dove L, McLaughlin AC, Emond J, Rattner L, D'Ovidio F, DiMango E. Combined Liver-Lung-Kidney Transplant in a Patient with Cystic Fibrosis. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e930867. [PMID: 34162826 PMCID: PMC8244370 DOI: 10.12659/ajcr.930867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Individuals with cystic fibrosis (CF) constituted approximately 10% of organ transplants in 2019, with the majority of transplants consisting of bilateral lung transplant. Multiorgan transplantation in individuals with cystic fibrosis (CF) is rare, and usually involves the liver and lung combined. Since kidney disease is not a common sequela of CF, the need for renal transplant in individuals who have not previously undergone lung transplant is uncommon. CASE REPORT We report a case of successful liver-lung-kidney transplant in a 23-year-old man with CF-related liver and lung disease, who developed renal failure due to IgA nephropathy. He required renal replacement therapy during the months before transplantation. After discussions among the liver, lung, and renal transplant teams, the patient was listed for multiorgan transplantation. An appropriate single donor for all organs was identified, and the patient underwent transplantation. The patient required extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) perioperatively, with total operative time of 23 h and 1 min. Postoperative course was notable for hemothorax and medication-induced acute tubular necrosis, which resolved without the need for renal replacement therapy. Liver and lung graft function was normal at 6 months, and renal function was minimally reduced. CONCLUSIONS Triple organ transplantation in CF is a viable option for individuals with multiorgan failure who may otherwise not qualify for single/dual organ transplantation. Use of ECMO and CRRT can be necessary during the long operative procedure. Optimal immunosuppression protocols for this group of patients has not yet been established, and ethical concerns regarding multiorgan transplantation exist.
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Affiliation(s)
- Lori Shah
- Department of Medicine, Columbia University Irving Medical Center, New York City, NY, USA
| | - Geoffrey Dube
- Department of Medicine, Columbia University Irving Medical Center, New York City, NY, USA
| | - Lorna Dove
- Department of Medicine, Columbia University Irving Medical Center, New York City, NY, USA
| | - Amy C McLaughlin
- Department of Medicine, Columbia University Irving Medical Center, New York City, NY, USA
| | - Jean Emond
- Department of Surgery, Columbia University Irving Medical Center, New York City, NY, USA
| | - Lloyd Rattner
- Department of Surgery, Columbia University Irving Medical Center, New York City, NY, USA
| | - Frank D'Ovidio
- Department of Surgery, Columbia University Irving Medical Center, New York City, NY, USA
| | - Emily DiMango
- Department of Medicine, Columbia University Irving Medical Center, New York City, NY, USA
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26
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Westphal SG, Langewisch ED, Robinson AM, Wilk AR, Dong JJ, Plumb TJ, Mullane R, Merani S, Hoffman AL, Maskin A, Miles CD. The impact of multi-organ transplant allocation priority on waitlisted kidney transplant candidates. Am J Transplant 2021; 21:2161-2174. [PMID: 33140571 DOI: 10.1111/ajt.16390] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Scott G Westphal
- Department of Internal Medicine, Nephrology Division, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Eric D Langewisch
- Department of Internal Medicine, Nephrology Division, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Amanda M Robinson
- Research Department, United Network of Organ Sharing, Richmond, Virginia, USA
| | - Amber R Wilk
- Research Department, United Network of Organ Sharing, Richmond, Virginia, USA
| | - Jianghu J Dong
- Department of Internal Medicine, Nephrology Division, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Department of Biostatistics, University of Nebraska Medical Center, College of Public Health, Omaha, Nebraska, USA
| | - Troy J Plumb
- Department of Internal Medicine, Nephrology Division, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Ryan Mullane
- Department of Internal Medicine, Nephrology Division, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Shaheed Merani
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Arika L Hoffman
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Alexander Maskin
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Clifford D Miles
- Department of Internal Medicine, Nephrology Division, University of Nebraska Medical Center, Omaha, Nebraska, USA
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27
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Beeckmans H, Bos S, Vos R. Selection Criteria for Lung Transplantation: Controversies and New Developments. Semin Respir Crit Care Med 2021; 42:329-345. [PMID: 34030197 DOI: 10.1055/s-0041-1728756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Lung transplantation is an accepted therapeutic option for end-stage lung diseases. The imbalance between limited availability and vast need of donor organs necessitates careful selection of recipient candidates, ensuring the best possible utilization of the scarce resource of organs. Nonetheless, possible lung transplant candidates who could experience a meaningful improvement in survival and quality of life should not be excluded solely based on the complexity of their case. In this review, controversial issues or difficult limitations for lung transplantation, and new developments in recipient selection criteria, are discussed, which may help broaden recipient eligibility for lung transplantation without compromising long-term outcomes.
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Affiliation(s)
- Hanne Beeckmans
- Division of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Saskia Bos
- Division of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Robin Vos
- Division of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), BREATHE, Leuven, Belgium
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28
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Altshuler PJ, Shah AP, Frank AM, Glorioso J, Dang H, Shaheen O, Patel K, Ramirez CB, Maley WR, Bodzin AS. Simultaneous liver kidney allocation policy and the Safety Net: an early examination of utilization and outcomes in the United States. Transpl Int 2021; 34:1052-1064. [PMID: 33884677 DOI: 10.1111/tri.13891] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 04/12/2021] [Indexed: 01/31/2023]
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.
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Affiliation(s)
- Peter J Altshuler
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ashesh P Shah
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam M Frank
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jaime Glorioso
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Hien Dang
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Osama Shaheen
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Keyur Patel
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Carlo B Ramirez
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Warren R Maley
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam S Bodzin
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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29
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Kumar A, Bonnell LN, Thomas CP. Impact of changing renal function, while waiting for a heart transplant, on post-transplant mortality and development of end stage kidney disease. Transpl Int 2021; 34:1044-1051. [PMID: 33884675 DOI: 10.1111/tri.13889] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/31/2021] [Accepted: 04/16/2021] [Indexed: 11/30/2022]
Abstract
Heart transplantation is a viable option for end stage heart disease but long-term complications such as chronic kidney disease are being increasingly recognized. We sought to investigate the effect of change in estimated glomerular filtration rate (eGFR) during the heart transplant waitlist period on post-transplant mortality and end stage kidney disease (ESKD). We analysed the United Network of Organ Sharing heart transplant database from 2000 to 2017. Multivariable Cox regression with restricted cubic splines and cumulative incidence competing risk (CICR) methods were used to compare the effects of change in eGFR on mortality and ESKD, respectively. A total of 19 412 patients met our inclusion criteria. Mortality increased with increasing loss of eGFR (adjusted hazard ratio increased from 1.02 [confidence interval (CI) 1.01-1.04, P = 0.008] for 10% loss to 1.15 (CI 1.06-1.26, P = 0.001) for 50% loss of eGFR. Similarly, risk of ESKD also increased monotonically with increasing loss of renal function [subdistribution hazard ratio increased from 1.12 (CI 1.09-1.14, P < 0.001) to 2.0 (CI 1.74-2.3, P < 0.001)] as loss of eGFR increased from 10% to 50%. Overall, we found that loss of >10% of eGFR resulted in higher risk of mortality and higher risk of ESKD.
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Affiliation(s)
- Abhishek Kumar
- Department of Internal Medicine, University of Vermont, Burlington, VT, USA
| | - Levi N Bonnell
- Department of General Internal Medicine Research, University of Vermont, Burlington, VT, USA
| | - Christie P Thomas
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.,Veterans Affairs Medical Center, Iowa City, IA, USA
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30
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Purvis J, McLeod C, Smith B, Orandi BJ, Kale C, Goldberg DS, Eckhoff DE, Locke JE, Cannon RM. Survival following simultaneous liver-lung versus liver alone transplantation: Results of the US National experience. Am J Surg 2021; 222:813-818. [PMID: 33589242 DOI: 10.1016/j.amjsurg.2021.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/24/2021] [Accepted: 01/31/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND There are little data to compare the post-transplant survival between lung-liver transplant (LLT) and liver-alone recipients. This study was undertaken to compare survival between LLT and liver-alone transplant. METHODS UNOS data for patients undergoing LLT from 2002 to 2017 was analyzed. LLT recipients (n = 81) were matched 1:4 to liver-alone recipients (n = 324) by propensity score and patient survival was compared in the matched cohorts. RESULTS Unadjusted 1, 3, and 5-year patient survival in the matched cohort was significantly worse in the LLT (82.5%, 72.2%, and 62.2%) versus liver-alone (92.2%, 82.8%, and 80.9%; p = 0.005). This difference persisted after adjusting for covariates with residual imbalance (HR 2.05, 95% CI 1.37-3.08; p = 0.001). CONCLUSION LLT has significantly worse survival than liver-alone transplant. With an increasing organ shortage, medical necessity criteria such as those developed for simultaneous liver-kidney transplantation should be developed for simultaneous lung-liver transplants to assure liver allografts are only allocated when truly needed.
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Affiliation(s)
- Joshua Purvis
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA
| | - Chandler McLeod
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA
| | - Blair Smith
- University of Alabama at Birmingham, Department of Anesthesia, Birmingham, AL, USA
| | - Babak J Orandi
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA
| | - Cozette Kale
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA
| | - David S Goldberg
- University of Miami Miller School of Medicine, Department of Medicine, Miami, FL, USA
| | - Devin E Eckhoff
- Beth Israel Deaconess Medical Center, Department of Surgery, Boston, MA, USA
| | - Jayme E Locke
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA
| | - Robert M Cannon
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, AL, USA.
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31
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Bari K, Sharma P. Optimizing the Selection of Patients for Simultaneous Liver-Kidney Transplant. Clin Liver Dis 2021; 25:89-102. [PMID: 33978585 DOI: 10.1016/j.cld.2020.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Simultaneous liver-kidney transplantation has increased significantly in the Model for End Stage Liver Disease era. The transplantation policy has evolved significantly since the implementation of allocation based on the Model for End Stage Liver Disease. Current policy takes into account the medical eligibility criteria for simultaneous liver-kidney transplantation listing. It also provides a safety net option and prioritizes kidney transplant after liver transplant recipients who are unlikely to recover their renal function within 60 to 365 days after liver transplant alone. This review seeks to understand the underlying challenges in carefully selecting the candidates while optimizing the patient selection.
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Affiliation(s)
- Khurram Bari
- Division of Gastroenterology and Hepatology, University of Cincinnati, 231 Albert Sabin Way, ML 0595, MSB 7259, Cincinnati, OH 45267, USA
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, 3912 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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32
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And Then There Were Three: Effects of Pretransplant Dialysis on Multiorgan Transplantation. Transplant Direct 2021; 7:e657. [PMID: 33490382 PMCID: PMC7817305 DOI: 10.1097/txd.0000000000001112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 11/15/2020] [Indexed: 11/18/2022] Open
Abstract
Background. Simultaneous liver-kidney (SLK) and simultaneous heart-kidney (SHK) transplantation currently utilize 6% of deceased donor kidneys in the United States. To what extent residual kidney function accounts for apparent kidney allograft survival is unknown. Methods. We examined all adult SLK and SHK transplants in the United States during 1995–2014. We considered the duration of dialysis preceding SLK or SHK (≥90 d, 1–89 d, or none) as a proxy of residual kidney function. We used multinomial logistic regression to estimate the difference in the adjusted likelihood of 6- and 12-month apparent kidney allograft failure between the no dialysis versus ≥90 days dialysis groups. Results. Of 4875 SLK and 848 SHK recipients, 1775 (36%) SLK and 449 (53%) SHK recipients received no dialysis before transplant. The likelihood of apparent kidney allograft failure was 1%–3% lower at 12 months in SLK and SHK recipients who did not require pretransplant dialysis relative to recipients who required ≥90 days of pretransplant dialysis. Among 3978 SLK recipients who survived to 1 year, no pretransplant dialysis was associated with a lower risk of apparent kidney allograft failure over a median follow-up of 5.7 years (adjusted hazard ratio 0.73 [0.55–0.96]). Conclusions. Patients with residual kidney function at the time of multiorgan transplantation are less likely to have apparent failure of the kidney allograft. Whether residual kidney function facilitates function of the allograft or whether some SLK and SHK recipients have 3 functional kidneys is unknown. Sustained kidney function after SLK and SHK transplants does not necessarily indicate successful MOT.
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33
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Defining a Willingness-to-transplant Threshold in an Era of Organ Scarcity: Simultaneous Liver-kidney Transplant as a Case Example. Transplantation 2020; 104:387-394. [PMID: 31107820 DOI: 10.1097/tp.0000000000002788] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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34
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Sade RM, Entwistle JWC. Limiting Multiorgan Transplantation: Your Patient Should Not Receive Two Organs While Mine Receives None. Ann Thorac Surg 2020; 111:771-777. [PMID: 32712097 DOI: 10.1016/j.athoracsur.2020.05.132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/13/2020] [Indexed: 01/13/2023]
Affiliation(s)
- Robert M Sade
- Division of Cardiothoracic Surgery, Department of Surgery, Institute of Human Values in Health Care, Charleston, Medical University of South Carolina, Charleston, South Carolina.
| | - John W C Entwistle
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
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35
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Punnoose LR, Rao S, Ghanta MM, Karhadkar SS, Alvarez R. Outcomes of Older Patients in the Recent Era of Heart Kidney Transplantation. Transplant Proc 2020; 53:341-347. [PMID: 32694056 DOI: 10.1016/j.transproceed.2020.04.1821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/14/2020] [Accepted: 04/25/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Variable age thresholds are often used at transplant centers for simultaneous heart and kidney transplantation (HKT). We hypothesize that selected older recipients enjoy comparable outcome to younger recipients in the current era of HKT. METHODS We performed a retrospective analysis of HKT outcomes in the United Network for Organ Sharing (UNOS) registry from 2006 to 2018, classifying patients by age at transplant as ≥ 65 or < 65 years. The primary outcome was patient death. Secondary outcomes included all-cause kidney graft failure and death-censored kidney allograft failure. RESULTS Of 973 patients, 774 (80%) were younger than 65 years (mean 52 ± 10 years) and 199 (20%) were 65 years or older (mean 67 ± 2 years). The older HKT cohort had fewer blacks (22% vs 35%, P = .01) and women (12 vs 18%, P = .04). Fewer older patients received dialysis (30% vs 54%, P < .001) and mechanical support (36% vs 45%, P = .03) before HKT. Older recipients received organs from slightly older donors. The median follow-up time was shorter for patients 65 years or older than for the younger group (2.3 vs 3.3 years, P < .001). Patient survival was similar between the groups (mean 8.8 vs 9.8 years, P = .3), with the most common causes of death being cardiovascular (29%) and infectious complications (28%). There was no difference in all-cause kidney graft survival (mean 8.7 vs 9.3 years, P = .8). Most commonly, recipients died with a functional renal allograft (59.8%), and this occurred more commonly in older patients (81.4% vs 54.8%, P = .001). Cox proportional hazard modeling showed that higher donor age (hazard ratio [HR] 1.015, P = .01; HR 1.022, P = .02) and use of pre-transplant dialysis (HR 1.5, P = .004; HR 1.8, P = .006) increased the risk for both all-cause and death-censored kidney allograft failure, respectively. CONCLUSIONS Our study showed that carefully selected older patients have outcomes similar to those of a younger cohort and argues for comprehensive evaluation of the recipients with age as part of comorbidity assessment rather than use of an arbitrary age threshold for candidacy.
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Affiliation(s)
- Lynn R Punnoose
- Vanderbilt Heart and Vascular Institute, Vanderbilt University School of Medicine, Nashville, TN, United States.
| | - Swati Rao
- Division of Nephrology, University of Virginia, Charlottesville, VA, United States
| | - Mythili M Ghanta
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Sunil S Karhadkar
- Temple Abdominal Transplant Program, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Rene Alvarez
- Division of Cardiology, Jefferson University Hospitals, Philadelphia PA, United States
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36
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Shaw BI, Sudan DL, Boulware LE, McElroy LM. Striking a Balance in Simultaneous Heart Kidney Transplant: Optimizing Outcomes for All Wait-Listed Patients. J Am Soc Nephrol 2020; 31:1661-1664. [PMID: 32499397 DOI: 10.1681/asn.2020030336] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Brian I Shaw
- Department of Surgery, Duke Transplant Center, Duke University, Durham, North Carolina
| | - Debra L Sudan
- Department of Surgery, Duke Transplant Center, Duke University, Durham, North Carolina
| | - L Ebony Boulware
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Lisa M McElroy
- Department of Surgery, Duke Transplant Center, Duke University, Durham, North Carolina
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37
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Cheng XS, Khush KK, Wiseman A, Teuteberg J, Tan JC. To kidney or not to kidney: Applying lessons learned from the simultaneous liver-kidney transplant policy to simultaneous heart-kidney transplantation. Clin Transplant 2020; 34:e13878. [PMID: 32279361 DOI: 10.1111/ctr.13878] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/27/2020] [Accepted: 04/01/2020] [Indexed: 12/15/2022]
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.
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Affiliation(s)
- Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | | | - Jeffrey Teuteberg
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jane C Tan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
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38
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Parajuli S, Arunachalam A, Swanson KJ, Aziz F, Garg N, Redfield RR, Kaufman D, Djamali A, Odorico J, Mandelbrot DA. Outcomes after simultaneous kidney‐pancreas versus pancreas after kidney transplantation in the current era. Clin Transplant 2019; 33:e13732. [PMID: 31628870 DOI: 10.1111/ctr.13732] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/28/2019] [Accepted: 10/14/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Annamalai Arunachalam
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Kurtis J. Swanson
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Fahad Aziz
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Neetika Garg
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Robert R. Redfield
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Dixon Kaufman
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Arjang Djamali
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Jon Odorico
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Didier A. Mandelbrot
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
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39
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Husain SA, King KL, Dube GK, Tsapepas D, Cohen DJ, Ratner LE, Mohan S. Regional Disparities in Transplantation With Deceased Donor Kidneys With Kidney Donor Profile Index Less Than 20% Among Candidates With Top 20% Estimated Post Transplant Survival. Prog Transplant 2019; 29:354-360. [PMID: 31506000 DOI: 10.1177/1526924819874699] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The Kidney Allocation System in the United States prioritizes candidates with Estimated Post-Transplant Survival (EPTS) ≤20% to receive deceased donor kidneys with Kidney Donor Profile Index (KDPI) ≤20%. RESEARCH QUESTION We compared access to KDPI ≤ 20% kidneys for EPTS ≤ 20% candidates across the United States to determine whether geographic disparities in access to these low KDPI kidneys exist. DESIGN We identified all incident adult deceased donor kidney candidates wait-listed January 1, 2015, to March 31, 2018, using United Network for Organ Sharing data. We calculated the proportion of candidates transplanted, final EPTS, and KDPI of transplanted kidneys for candidates listed with EPTS ≤ 20% versus >20%. We compared the odds of receiving a KDPI ≤ 20% deceased donor kidney for EPTS ≤ 20% candidates across regions using logistic regression. RESULTS Among 121 069 deceased donor kidney candidates, 28.5% had listing EPTS ≤ 20%. Of these, 16.1% received deceased donor kidney transplants (candidates listed EPTS > 20%: 17.1% transplanted) and 12.3% lost EPTS ≤ 20% status. Only 49.4% of transplanted EPTS ≤ 20% candidates received a KDPI ≤ 20% kidney, and 48.3% of KDPI ≤ 20% kidneys went to recipients with EPTS > 20% at the time of transplantation. Odds of receiving a KDPI ≤ 20% kidney were highest in region 6 and lowest in region 9 (odds ratio 0.19 [0.13 to 0.28]). The ratio of KDPI ≤ 20% donors per EPTS ≤ 20% candidate and likelihood of KDPI ≤ 20% transplantation were strongly correlated (r 2 = 0.84). DISCUSSION Marked geographic variation in the likelihood of receiving a KDPI ≤ 20% deceased donor kidney among transplanted EPTS ≤ 20% candidates exists and is related to differences in organ availability within allocation borders. Policy changes to improve organ sharing are needed to improve equity in access to low KDPI kidneys.
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Affiliation(s)
- S Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY, USA.,The Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY, USA.,The Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | - Geoffrey K Dube
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | | | - David J Cohen
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Lloyd E Ratner
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY, USA.,The Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
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Sharma P. Liver-Kidney: Indications, Patient Selection, and Allocation Policy. Clin Liver Dis (Hoboken) 2019; 13:165-169. [PMID: 31316763 PMCID: PMC6605734 DOI: 10.1002/cld.787] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 11/24/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Pratima Sharma
- Department of Gastroenterology and HepatologyUniversity of Michigan Institute of Healthcare Policy & InnovationAnn ArborMI
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Han JL, Beal EW, Mumtaz K, Washburn K, Black SM. Combined liver-lung transplantation: Indications, outcomes, current experience and ethical Issues. Transplant Rev (Orlando) 2019; 33:99-106. [DOI: 10.1016/j.trre.2018.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/14/2018] [Accepted: 11/15/2018] [Indexed: 01/29/2023]
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Comparing Simultaneous Liver-Kidney Transplant Strategies: A Modified Cost-Effectiveness Analysis. Transplantation 2019; 102:e219-e228. [PMID: 29554056 DOI: 10.1097/tp.0000000000002148] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Tafesse E. The kidney allocation system and its implications for pediatric recipients. Am J Transplant 2018; 18:1824. [PMID: 29673095 DOI: 10.1111/ajt.14881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Chan JL, Miller JG, Singh AK, Horvath KA, Corcoran PC, Mohiuddin MM. Consideration of appropriate clinical applications for cardiac xenotransplantation. Clin Transplant 2018; 32:e13330. [DOI: 10.1111/ctr.13330] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Joshua L. Chan
- Cardiothoracic Surgery Research Program/National Heart; Lung and Blood Institute; National Institutes of Health; Bethesda MD USA
| | - Justin G. Miller
- Cardiothoracic Surgery Research Program/National Heart; Lung and Blood Institute; National Institutes of Health; Bethesda MD USA
| | - Avneesh K. Singh
- Cardiothoracic Surgery Research Program/National Heart; Lung and Blood Institute; National Institutes of Health; Bethesda MD USA
| | - Keith A. Horvath
- Cardiothoracic Surgery Research Program/National Heart; Lung and Blood Institute; National Institutes of Health; Bethesda MD USA
| | - Philip C. Corcoran
- Cardiothoracic Surgery Research Program/National Heart; Lung and Blood Institute; National Institutes of Health; Bethesda MD USA
| | - Muhammad M. Mohiuddin
- Cardiothoracic Surgery Research Program/National Heart; Lung and Blood Institute; National Institutes of Health; Bethesda MD USA
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Defining kidney allograft benefit from successful pancreas transplant: separating fact from fiction. Curr Opin Organ Transplant 2018; 23:448-453. [PMID: 29878910 DOI: 10.1097/mot.0000000000000547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW To define the natural history of kidney allograft loss related to recurrent diabetes following transplant, and to understand the potential benefit of pancreas transplantation upon kidney allograft survival. RECENT FINDINGS A postulated benefit of simultaneous pancreas kidney transplant is that, unlike kidney transplant alone, euglycemia from the added pancreas allograft may confer a nephroprotective benefit and prevent recurrent diabetic nephropathy in the renal allograft. Recent large database analyses and long-term histological assessments have been published that assist in quantifying the problem of recurrent diabetic nephropathy and answering the question of the potential benefits of euglycemia. Further data may be extrapolated from larger single-center series that follow the prognosis of early posttransplant diabetes mellitus as another barometer of risk from diabetic nephropathy and graft loss. SUMMARY Recurrent diabetic nephropathy following kidney transplant is a relatively rare, late occurrence and its clinical significance is significantly diminished by the competing risks of death and chronic alloimmune injury. Although there are hints of a protective effect upon kidney graft survival with pancreas transplant, these improvements are small and may take decades to appreciate. Clinical decision-making regarding pancreas transplant solely based upon nephroprotective effects of the kidney allograft should be avoided.
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Simultaneous Liver-Kidney Transplantation: Impact on Liver Transplant Patients and the Kidney Transplant Waiting List. CURRENT TRANSPLANTATION REPORTS 2018; 5:1-6. [PMID: 29564203 PMCID: PMC5843696 DOI: 10.1007/s40472-018-0175-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
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.
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Utility in Treating Kidney Failure in End-Stage Liver Disease With Simultaneous Liver-Kidney Transplantation. Transplantation 2017; 101:1111-1119. [PMID: 28437790 PMCID: PMC5079265 DOI: 10.1097/tp.0000000000001491] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Simultaneous liver-kidney (SLK) transplantation plays an important role in treating kidney failure in patients with end-stage liver disease. It used 5% of deceased donor kidney transplanted in 2015. We evaluated the utility, defined as posttransplant kidney allograft lifespan, of this practice. Methods Using data from the Scientific Registry of Transplant Recipients, we compared outcomes for all SLK transplants between January 1, 1995, and December 3, 2014, to their donor-matched kidney used in kidney-alone (Ki) or simultaneous pancreas kidney (SPK) transplants. Primary outcome was kidney allograft lifespan, defined as the time free from death or allograft failure. Secondary outcomes included death and death-censored allograft failure. We adjusted all analyses for donor, transplant, and recipient factors. Results The adjusted 10-year mean kidney allograft lifespan was higher in Ki/SPK compared with SLK transplants by 0.99 years in the Model for End-stage Liver Disease era and 1.71 years in the pre-Model for End-stage Liver Disease era. Death was higher in SLK recipients relative to Ki/SPK recipients: 10-year cumulative incidences 0.36 (95% confident interval 0.33-0.38) versus 0.19 (95% confident interval 0.17-0.21). Conclusions SLK transplantation exemplifies the trade-off between the principles of utility and medical urgency. With each SLK transplantation, about 1 year of allograft lifespan is traded so that sicker patients, that is, SLK transplant recipients, are afforded access to the organ. These data provide a basis against which benefits derived from urgency-based allocation can be measured. This analysis of the UNOS data demonstrated that SLK patients had decreased long term renal graft function that SPK patients. This analysis demonstrates the difficult policy choices epitomized by prioritizing the SLK population and its impact of utility considerations. Supplemental digital content is available in the text.
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