Simultaneous Liver-Kidney Transplant vs. Safety Net Kidney after Liver Transplant: How Has the Policy Change Impacted Graft and Patient Outcomes?

Background: The policy governing the eligibility criteria for simultaneous liver-kidney transplant (SLK) was implemented on Aug 10, 2017. After policy change, liver transplant patients can be listed for kidney transplants (KAL) by the safety net criteria between posttransplant days 60 to 365 if they have a qualifying eGFR of <20 ml/min. The impact of this policy change for transplant recipients at our center is not known. Methods: Demographic information for recipients and donors, chronic kidney and liver disease history, transplant characteristics, graft function and patient survival information were collected by chart review for transplants occurring between Aug 10, 2017 and Mar 31, 2023. Rates of primary non function (PNF), death, rejection, and time between waitlisting and transplant were collected for all patients listed for liver and kidney transplant. Results: There was a total of 49 SLK recipients and 16/37 liver transplant patients who were listed for KAL received a kidney transplant. The proportion of patients on dialysis at the time of listing for SLK and KAL was 57% (N=21) vs 63% (N=23). Hepatorenal syndrome was a cause of kidney disease in 31% (N=15) vs 46% (N=17) patients of SLK vs KAL recipients. 2 SLK recipients developed PNF whereas none of the KAL recipients developed PNF. 14 KAL patients (88%) received the kidney transplant within 2 years of a liver transplant. Among KAL listing, 81% (N=30) occurred within the safety net period. The mean eGFR at 1 year post transplant was 55 and 61 ml/min for SLK vs KAL. Two patients on KAL waitlist recovered kidney function and were removed from the waitlist. Conclusion: Most patients receiving a liver alone received a kidney transplant within 2 years of the liver transplant, most often through the safety net criteria. The patients receiving KAL had comparable allograft function, rejection and patient survival rates to SLK patients. Some patients on KAL waitlist recovered kidney function and were removed from the waitlist allowing these kidneys to be allocated to patients listed for a kidney transplant alone. Identification of patients that may be able to get KAL transplant may allow for improved access to kidney transplant for others on the deceased donor kidney transplant waitlist.