FATE OF LIVER AND KIDNEY TRANSPLANT CANDIDATES BEFORE AND AFTER SIMULTANEOUS LIVER-KIDNEY TRANSPLANT ALLOCATION POLICY CHANGE
Shimada S, Kitajima T, Lisznyai E, Suzuki Y, Kuno Y, Flores A, Sukkarieh N, Collins K, Rizzari M, Yoshida A, Abouljoud MS, and Nagai S. FATE OF LIVER AND KIDNEY TRANSPLANT CANDIDATES BEFORE AND AFTER SIMULTANEOUS LIVER-KIDNEY TRANSPLANT ALLOCATION POLICY CHANGE. Hepatology 2020; 72:40A-40A.
Background: The OPTN/UNOS policy for kidney allocation to liver transplant (LT) recipients was implemented on August 10th, 2017. We investigated the impact of the policy change on outcomes on simultaneous liver-kidney transplantation (SLK) candidates.
Methods: Using OPTN/UNOS data, we analyzed adult SLK candidates between January 2015 and March 2019. We excluded patients registered for retransplant. Patients were classified into two cohorts; cohort 1: from January 1st, 2015 to July 31st, 2017 (pre-policy group), cohort 2: from September 1st, 2017 to March 30th, 2019 (post-policy group). Waitlist outcomes, including 90-day mortality, transplant probability, and type of transplant (SLK vs. LT alone [LTA]) were compared between the two cohorts using a Fine-Gray competing risk regression model. Post-transplant outcomes were compared according to transplant type using a Cox regression model.
Results: Of the 4641 patients eligible for this study, 2975 and 1666 were registered in cohorts 1 and 2, respectively. The average number of waitlisted patients (daily) was significantly lower in cohort 2 compared to cohort 1 (2.89/day vs. 3.25/day; p=0.013). In patients with MELD score >35, there was significantly higher 90-day transplant probability in cohort 2 (adjusted hazard ratio [aHR]:1.23, p=0.032); whereas no significant difference was observed in patients with MELD scores 30-34 or <29. The patients in cohort 2 with MELD scores ≥35 trended towards a lower 90- day waitlist mortality compared to patients in cohort 1 (aHR: 0.69, p=0.06). Regarding transplant type, the proportion of LTA in SLK candidates was significantly higher in cohort 2 compared to cohort 1; both overall (7.9% vs. 3.0%, P<0.001) and when stratified by MELD score (≤29, 30-34, ≥35; p=0.006, 0.008, 0.004, respectively) (Figure 1). Adjusted risk of 1-year graft loss was significantly higher in LTA compared to SLK (aHR 2.01, p=0.012) (Figure 2).
Conclusion: The new SLK policy significantly decreased the number of SLK transplants while significantly improving waitlist outcomes, especially in patients with higher MELD scores. After the policy change, patients who were initially registered for SLK more frequently received LTA, likely due to more stringent criteria. Because LTA outcomes were significantly worse than SLK in SLK candidates, the decision on transplant type for this patient population needs careful assessment.