The Kidney Drain: Effect of Simultaneous Liver Kidney Transplantation on Deceased Donor Kidney Allocation After Implementation of the New Liver Allocation Policy
Jennifer M. Brewer1, Leah Aakjar2, David O'Sullivan2, Wasim Dar3, Zeynep Ebcioglu3, Michael Einstein3, Glyn Morgan3, Bishoy Emmanuel3, Xiaoyi Ye3, Joseph Singh3, Eva Urtasun Sotil3, Colin Swales3, Rebecca Kent3, Elizabeth Richardson3, william Sardella3, Oscar Serrano3
1Surgery, University School of Medicine, Farmington, Connecticut, United States, 2Research, Hartford Hospital, Hartford, Connecticut, United States, 3Transplant & Comprehensive Liver Center, Hartford Hospital, Hartford, Connecticut, United States
Introduction: The new liver allocation policy (NLAP) has shown improvements in solitary liver transplant (LT) rates but its effect on other solid organ transplants is unknown. The NLAP has likely resulted in changes in the distribution of deceased donor kidneys, especially in the setting of simultaneous liver kidney (SLK) transplantation. We sought to review SLK patterns before and after the institution of NLAP and determine if SLK rate changes were associated with a change in kidney transplantation (KT) and patient and graft survival. Methods: Data from the Organ Procurement Transplant Network (OPTN) was analyzed to evaluate rates of SLK and KT transplantation before and after the implementation of NLAP. Era 1 was defined as January 1, 2018 to February 3, 2020; Era 2 was defined as February 4, 2020 to June 1, 2021. Statistical comparisons between eras were performed. Transplant programs were divided into high (25%ile), medium (26-74%ile), and low volume (75%ile) SLK programs according to Era 1. Similarly, transplant programs were divided into high (25%ile), medium (26-74%ile), and low volume (75%ile) KT programs according to Era 1. Transplant volume was assessed for Era 2. Results: We analyzed 28,085 SLK and 75,058 KT performed in adult recipients from January 1, 2018 to June 1, 2021; 16,799 SLK and 45,168 KT were performed in Era 1 and 11,286 SLK and 29,890 KT were performed in Era 2. For SLK recipients during Era 1, the 1- and 3-year patient survival was 90.3% and 75.9%, respectively; the 1- and 3-year graft survival was 97.4% and 96.8%, respectively. During Era 2, the 1-year patient and graft survival for SLK recipients was 85.8% and 97.5%, respectively. For KT recipients during Era 1, the 1- and 3-year patient survival was 97.1% and 87.6%, respectfully; graft survival was 97.5% and 93.1%, respectively. During Era 2, the 1-year patient and graft survival for KT recipients was 93.2% and 96.9%, respectively. As a result of NLAP, 1,008 additional kidneys went to SLK recipients. Changes in volume were most evident for low-volume SLK centers with an average increase of 1.4 to 8 transplants per year, while medium- and high-volume centers had a reduction in volume. Conversely, KT programs had an overall reduction in volume with medium- and high-volume KT centers seeing the largest drop in KT volume. Conclusion: The institution of the NLAM led to a net efflux of kidneys from the solitary KT candidate pool. Interestingly, patient survival decreased while graft survival improved for SLK recipients while both patient and graft survival decreased for KT as a result of NLAM. Further research is necessary to balance the fair and equitable distribution of liver allografts whilst not adversely affecting the solitary KT candidates.
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