Recent changes in the criteria for simultaneous liver and kidney transplantation (SLKT) are likely to change organ allocation. The evidence supporting SLKT except in patients with end stage renal disease is weak, suggesting fewer SLK transplantations going forward. At the same time, the new criteria will streamline the allocation of kidneys for liver transplantation recipients who later need a new kidney.
“The new SLKT policy from the Organ Procurement and Transplantation Network (OPTN) gives us the first medical eligibility criteria for local and regional SLK allocation, said Pratima Sharma, MD, MS, Associate Professor of Internal Medicine at the University of Michigan. “It also gives us a safety net by prioritizing liver transplant recipients who depend on dialysis or have significant renal dysfunction on the kidney-alone waiting list.”
Dr. Sharma discussed the new SLKT criteria during a Saturday symposium sponsored by the Liver Transplantation and Surgery Special Interest Group. The new criteria are expected to reduce the variability in allocation across OPTN regions created by MELD-based criteria in 2002. The liver community can also expect to see a reduction in the increase in SLKT that began with the last OPTN policy in 2009.
“Prior policy had almost no rules for SLK allocation, which meant candidates were not being treated equitably,” Dr. Sharma said. “Policy did not specify any medical criteria for assessing kidney function when a kidney was allocated to a liver-kidney candidate. Policy simply stated that if donor and candidate are local, the kidney will be allocated with the liver. That runs counter to the OPTN final rule that allocation policies must be based on sound medical judgment and standardized criteria, seek the best use of organs and avoid futile transplants.”
In order to qualify for SLKT, the transplant nephrologist must confirm that the candidate has one of the following: chronic kidney disease with measured or calculated GFR of 60 mL/min for more than 90 days, sustained acute kidney injury or an inherited metabolic disease.
The transplant center must also document one specific indication in the medical record: dialysis for ESRDFR/CrCL of 35 mL/min or less at registration on the kidney waiting list; dialysis for six consecutive weeks, eGFR/CrCL of 25 mL/min or less for at lest six consecutive weeks or any combination for six consecutive weeks; or hyperoxaluria, atypical HUS with mutations in factor H and possibly factor I, familial non-neuropathic systemic amyloid or methylmalonic aciduria.
OPTN did not specify a uniform method for measuring or calculating GFR, Dr. Sharma added. There is continuing debate about the accuracy of different measurements and compliance with a uniform method would be difficult to monitor.
“This is a step forward for streamlining the allocation process,” she concluded.