Simultaneous Liver-Kidney Transplantation: Policy Update and the Challenges Ahead

OPTN Policy (K Andreoni, Section Editor)
Part of the following topical collections:
  1. Topical Collection on OPTN Policy

Abstract

Purpose of the Review

Institution of a Simultaneous Liver Kidney (SLK) policy by the OPTN in 2016 represented the culmination of more than a decade of consensus conferences, public comments, and inter-society cooperation. The debates produced a multi-tiered proposal that established medical eligibility criteria for kidney allocation, a requirement for the regional sharing of a kidney to a MELD 35 medical eligible candidate and creation of a safety net for patients receiving a liver-alone transplant with subsequent kidney failure within the first post transplant year.

Recent Interventions

The stratifications and alterations represented the first time that eligibility requirements have been instituted for allocating a multi-organ combination that is not tracked by the Scientific Registry of Transplant Recipients (SRTR). The provisions for reporting and follow-up of the allocation alteration have been identified and will be reported at regular intervals to the OPTN for public release. Although there are multiple interventions to limit the kidney utilization to those candidates with true medical necessity, it is unknown how this will impact the overall distribution of the kidneys, especially with the safety net now being offered to candidates that would not have met medical eligibility at the time of their transplant. As SLK comprises over 10% of all liver transplants, the requirement change may be significant and would hopefully result in the more efficient use of kidneys without a negative impact on patient survival. Although utilization would be much better monitored, the outcome measures would still be lacking.

Summary

Even with this landmark change, review of the allocation process that presently favors allocating a kidney to a multi-organ transplant before allocation to a kidney-alone recipient is examined, especially as the prioritization affects pediatric candidates. It is hoped that advancements in this area would bring allocation policies into greater alignment with the intentions of the Final Rule legislation.

Keywords

Simultaneous liver-kidney transplantation Multi-organ transplantation UNOS medical eligibility policy Kidney allocation Kidney safety net Liver-kidney transplant outcomes 

Notes

Compliance with Ethical Standards

Conflict of Interest

The author declares that he has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    OPTN Policy 5.10.C: optn.transplant.hrsa.org.
  2. 2.
    Malinchoc M, Kamath P, Gordon F, et al. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000;31(4):864–71.CrossRefPubMedGoogle Scholar
  3. 3.
    Freeman RB Jr, Wiesner RH, Harper A, et al. The new liver allocation system: moving towards evidence-based transplantation policy. Liver Transpl. 2002;8:851–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Wiesner R, Edwards E, Freeman R, Harper A, Kim R, Kamath P, et al. Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology. 2003;124:91–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Formica RN. Simultaneous liver kidney transplantation. Curr Opin Nephrol Hypertens. 2016;25:577–82.CrossRefPubMedGoogle Scholar
  6. 6.
    Nair S, Verma S, Thuluvath PJ. Pretransplant renal function predicts survival in patients undergoing orthotopic liver transplantation. Hepatology. 2002;35:1179–85.CrossRefPubMedGoogle Scholar
  7. 7.
    Davis CL, Feng S, Sung R, Wong F, Goodrich NP, Melton LB, et al. Simultaneous liver-kidney transplantation: evaluation to decision making. Am J Transplant. 2007;7:1702–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Fong TL, Khemichian S, Shah T, Hutchinson IV, Chou YW. Combined liver kidney transplant is preferable to liver transplant alone for cirrhotic patients with renal failure. Transplantation. 2012;94:411–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Eason JD, Gonwa TA, Davis CL, Sung RS, Gerber D, Bloom RD. Proceedings of consensus conference on simultaneous liver kidney transplantation (SLK). Am J Transprant. 2008;8:2243–51.CrossRefGoogle Scholar
  10. 10.
    Gonwa TA, McBride MA, Anderson K, Mai ML, Wadei H, Ahsan N. Continued influence of preoperative renal function on outcome of orthotopic liver transplant (OLTX) in the US: where will MELD lead us? Am J Transplant. 2006;6:2651–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Simpson N, Chou YW, Cicciarelli JC, Selby RR, Fonf TL. Comparison of renal graft outcomes in combined liver-kidney transplantation versus subsequent kidney transplantation in liver transplant recipients: analysis of UNOS database. Transplantation. 2006;82:1298–303.CrossRefPubMedGoogle Scholar
  12. 12.
    Schmitt TM, Kumer SC, Al-Osaimi A, et al. Combined liver-kidney transplantation in patients with renal failure outcomes in the MELD era. Eur Soc Organ Transplant. 2009;22:876–83.CrossRefGoogle Scholar
  13. 13.
    Israni AK, Xiong H, Liu J, Salkowski N, Trotter JF, Snyder JJ, et al. Predicting end-stage renal disease after liver transplant. Am J Transplant. 2013;13:1782–92.CrossRefPubMedGoogle Scholar
  14. 14.
    Ruebner R, Goldberg D, Abt PL, Bahirwani R, Levine M, Sawinski D, et al. Risk of end-stage renal disease among liver transplant recipients with pretransplant renal dysfunction. Am J Transplant. 2012;12:2958–65.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Locke JL, Warren DS, Singer AL, et al. Declining outcomes in simultaneous liver-kidney transplantation in the MELD era: ineffective use of renal allografts. Transplantation. 2008;85:935–42.CrossRefPubMedGoogle Scholar
  16. 16.
    Sharma P, Shu X, Schaubel DE, Sung RS, Magee JC. Propensity score based survival benefit of simultaneous liver-kidney transplant over liver transplant alone for recipients with pretransplant renal dysfunction. Liver Transpl. 2016;22:71–9.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Campbell MS, Kotyar DS, Brensinger CM, et al. Renal function after orthotopic liver transplantation is predicted by duration of pretransplantation creatinine elevation. Liver Transpl. 2005;11(9):1022–5.CrossRefGoogle Scholar
  18. 18.
    Bahirwani R, Campbell MS, Siropaides T, Markmann J, Olthoff K, Shaked A, et al. Transplantation: impact of pretransplant renal insufficiency. Lever Transpl. 2008;14:665–71.CrossRefGoogle Scholar
  19. 19.
    Hmoud B, Yong-Fang K, Wiesner RH, Singal AK. Outcomes of liver transplantation alone after listing for simultaneous kidney: comparison to simultaneous liver kidney transplantation. Transplantation. 2015;99:823–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Sharma P, Goodrich NP, Zhang M, Guidinger MK, Schaubel DE, Merion RM. Short-term pretransplant renal replacement therapy and renal nonrecovery after liver transplantation alone. Clin J Am Soc Nephrol. 2013;8(7):1135–42.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Brennan TV, Lunsford KE, Vagefi PA, Bostrom A, Ma M, Feng S. Renal outcomes of simultaneous liver-kidney transplantation compared to liver transplant alone for candidates with renal dysfunction. Clin Transpl. 2015 Jan;29(1):34–43.CrossRefGoogle Scholar
  22. 22.
    Sanchez EQ, Gonwa TA, Levy MF, Goldstein RM, Mai ML, Hays SR, et al. Preoperative and perioperative predictors of the need for renal replacement therapy after orthotopic liver transplantation. Transplantation. 2004;78:1048–54.CrossRefPubMedGoogle Scholar
  23. 23.
    Levitsky J, Baker T, Ahya SN, Levin ML, Friedewald J, Gallon L, et al. Outcomes and native kidney recovery following simultaneous liver-kidney transplantation. Am J Transplant. 2012;12:2949–57.CrossRefPubMedGoogle Scholar
  24. 24.
    Nadim MK, Sung RS, Davis CL, Andreoni KA, Biggins SW, Danovitch GM, et al. Simultaneous liver-kidney transplantation summit: current state and future directions. Am J Transplant. 2012;12:2901–8.CrossRefPubMedGoogle Scholar
  25. 25.
    • Formica RN, Aeder M, Boyle G, Kucheryavaya A, Stewart D, Hirose R, et al. Simultaneous liver-kidney allocation policy: proposal to optimize appropriate utilization of scarce resources. Am J Transplant. 2016;16:758–66. This paper describes the background and discussions of the initial policy proposal that was circulated in 2015. The final policy was based on this framework. CrossRefPubMedGoogle Scholar
  26. 26.
    Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification and stratification. Ann Intrern Med. 2003;139:605.Google Scholar
  27. 27.
    Beben T, Rifkin DE. GFR estimating equations and liver disease. Adv Chronic Kidney Dis. 2015;22:337–42.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Sherman DS, Fish DN, Teitebaum I. Assessing renal function in cirrhotic patients: problems and pitfalls. Am J Kidney Dis. 2003;41:269–78.CrossRefPubMedGoogle Scholar
  29. 29.
    •• Asch WS, Bia MJ. New organ allocation system for combined liver-kidney transplants and the availability of kidneys for transplant to patients with stage 4–5 CKD. Clin J Am Soc Nephrol. 2017;12:848–52. Examines the potential implications of the new SLK policy. As there was no modeling data available from SRTR or within the UNOS database, the authors raise the issue of potential increases in SLK due to more medically eligible candidates or the increased utilization of the safety net. CrossRefPubMedGoogle Scholar
  30. 30.
    Final Rule National Organ Transplant Act (NOTA) of 1984 (42 U.S.C. 273, et seq).Google Scholar
  31. 31.
    Stewart DE, Kucheryavaya AY, Klassen DK, Turgeon NA Formica RN, Aeder MI. Changes in deceased donor kidney transplantation one year after KAS implementation. Am J Transplant. 2016;16:1834–47.CrossRefPubMedGoogle Scholar
  32. 32.
    Choudhury RA, Reese PP, Goldberg DS, Bloom RD, Sawinski DL, Abt PL. A paired analysis of multi-organ transplantation: Implications for allograft survival. Transplantation. 2017;101(2):368–76.CrossRefPubMedGoogle Scholar
  33. 33.
    Lunsford KE, Bodzin AS, Markovic D, Zarrinpar A, Kaldas FM, Gritsch HA, et al. Avoiding futility in simultaneous liver-kidney transplantation: analysis of 331 consecutive patients listed for dual organ replacement. Ann Surg. 2017;265(5):1016–24.CrossRefPubMedGoogle Scholar
  34. 34.
    Aeder M, Stewart D, Kucheryavaya A. UNOS data: unpublished.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Transplantation, Department of Surgery, Case Western Reserve UniversityUniversity Hospitals Cleveland Medical CenterClevelandUSA

Personalised recommendations