PARADIGM CHANGE IN LIVER TRANSPLANT PRACTICE FOR PATIENTS WITH KIDNEY DYSFUNCTION AFTER THE IMPLEMENTATION OF THE NEW LIVER-KIDNEY ALLOCATION POLICY
Suzuki Y, Kitajima T, Flores A, Shimada S, Kuno Y, Lisznyai E, Sukkarieh N, Collins K, Rizzari M, Yoshida A, Abouljoud MS, and Nagai S. PARADIGM CHANGE IN LIVER TRANSPLANT PRACTICE FOR PATIENTS WITH KIDNEY DYSFUNCTION AFTER THE IMPLEMENTATION OF THE NEW LIVER-KIDNEY ALLOCATION POLICY. Hepatology 2020; 72:1A-1A.
Background: The new OPTN/UNOS policy regarding kidney allocation for liver transplant (LT) patients was implemented on Aug 10, 2017. Per the new policy, LT patients who developed kidney failure may be granted priority on the kidney transplant (KT) waitlist (Safety net). The aim of this study was to evaluate effects of the new policy on pre and post-transplant practice LT patients with kidney dysfunction.
Methods: We analyzed adult primary LT alone (LTA) candidates who had kidney dysfunction at listing (Chronic kidney disease [CKD] stage 4 or higher) between January 2015 and March 2019 using data from the OPTN/UNOS. Impact of the new policy on the number of listings, waitlist outcomes, post-transplant outcomes, and KT listing after LTA were assessed. In post- LTA outcome analysis, patients were categorized according to kidney function at transplant (Group 1: CKD stage 4 without dialysis; Group 2: CKD stage 5 without dialysis; Group 3: dialysis requirement; Group 4: CKD stage 1-3 without dialysis).
Results: A total of 3821 patients with CKD 4 or higher were registered for LTA. The daily number of patients on dialysis who were registered for LTA significantly increased in post- policy era compared with pre-policy era (1.21/day vs 0.95/ day, p <0.001). 90-day LT waitlist mortality (HR 0.99, p=0.94) or transplant probability (HR 1.07, p=0.25) was not changed in post-policy era, compared to pre-policy era. One-year liver graft survival in Groups 1, 2, 3, and 4 were comparable between before and after the policy implementation (Table 1). Of all LTA patients, the patients in post-policy era had a higher risk for KT listing after LTA than those in pre-policy era (6.2% vs 3.9%, odds ratio = 3.30, p <0.001), especially patients in Group 3, 8.4% vs 2.0% (odds ratio = 4.38, p <0.001) (Table 2). Among the 65 patients who were listed for KT in post- policy era, one-year KT probability, waitlist mortality rate, and removal rate due to clinical improvement rate were 61.1%, 1.5%, and 2.7%, respectively.
Conclusion: The new policy significantly increased the number of LTA candidates with dialysis, did not affect their post-transplant survival, and increased KT listing after LTA. 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 new policy successfully stratified patients with kidney dysfunction for LTA and provided KT opportunities to patients post-LT kidney failure.