Paradigm change in liver transplant practice after the implementation of the liver-kidney allocation policy
Nagai S, Suzuki Y, Kitajima T, Ivanics T, Shimada S, Kuno Y, Shamaa MT, Yeddula S, Samaniego M, Collins K, Rizzari M, Yoshida A, and Abouljoud M. Paradigm change in liver transplant practice after the implementation of the liver-kidney allocation policy. Liver Transpl 2021.
The OPTN/UNOS policy regarding kidney allocation for liver transplant (LT) patients was implemented in August 2017. This study aimed to evaluate the effects of the simultaneous liver-kidney transplant policy on outcomes in LT alone (LTA) patients with kidney dysfunction. We analyzed adult primary LTA patients with kidney dysfunction at listing (estimated glomerular filtration rate [eGFR] less than 30mL/min or dialysis requirement) between January 2015 and March 2019 using the OPTN/UNOS registry. Waitlist practice and kidney transplant (KT) listing after LTA were compared between pre- and post-policy groups. 3,821 LTA listings with eGFR<30mL/min were included. The daily number of listings on dialysis was significantly higher in Era2 (post-policy group) than Era1 (pre-policy group) (1.21/day vs. 0.95/day, P<0.001). Of these LTA listings, 90-day LT waitlist mortality, LTA probability, and one-year post-LTA survival were similar between eras. LTA recipients in Era2 had a higher probability for KT listing post-LTA than those in Era1 (6.2% vs. 3.9%, odds ratio=3.30, P<0.001), especially those on dialysis (8.4% vs. 2.0%, odds ratio=4.38, P<0.001). Under the safety-net rule, there was a higher KT probability after LTA (26.7% and 53% at 6 months in Eras 1 and 2, respectively, P=0.017).
Conclusion: After the implementation of the policy, the number of LTA listings among patients on dialysis significantly increased. While their post-transplant survival was not changed, KT listing after LTA increased. The safety-net rule led to high KT probability and low waitlist mortality rate in patients who were listed for KT after LTA. These results suggest that the policy successfully achieved the goals, which did not compromise LTA waitlist or post-transplant outcomes in patients with kidney dysfunction, and provided KT opportunities if they developed kidney failure after LTA.
ePub ahead of print