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

Abstract

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. 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. 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.