COMMENTARY

A Simultaneous Liver-Kidney Transplant? Not So Fast

Jeffrey S. Berns, MD; Peter P. Reese, MD

Disclosures

May 17, 2016

Editorial Collaboration

Medscape &

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Jeffrey S. Berns, MD: Hello. This is Jeffrey Berns, editor-in-chief of Medscape Nephrology. I'm here with one of my colleagues, Dr Peter Reese, assistant professor of medicine and a transplant nephrologist. He is also chair of the Ethics Committee at the United Network for Organ Sharing (UNOS), which is the organization that oversees organ transplantation in the United States. There has been a proposal by UNOS to change the rules for transplantation of kidneys in patients who are being given a liver transplant—or in other words, a simultaneous liver-kidney transplant.

Peter, maybe you can first tell our viewers what the problem is. Why does UNOS think there is a need to change the rules for simultaneous liver-kidney transplants?

Peter P. Reese, MD: I think these changes are welcome and overdue. I'm glad that they're happening. The crux of the issue is that there aren't enough organs, particularly enough kidneys, to go around. The waiting list has more than 100,000 people waiting for a kidney.

We have to ration these organs. It's important that the rules are both fair and efficient. Without that, public trust is at stake.

Right now, the fundamental problem is that if you rise to the top of the list for a liver transplant, your transplant center can basically demand that the kidney from that same donor be provided to that patient. For the liver, there's a reason why they're at the top of the liver transplant waiting list, and you have to document that reason. But if they want the kidney as well, they don't have to do anything other than ask. There are no objective medical criteria. Second, it's probably not fair in some circumstances to other people on the kidney transplant waiting list.

You can picture it in your head. The worst possible scenario would be when a patient gets a liver and a kidney, and the person who didn't get that kidney might be a child—4 years old on dialysis—or someone who is highly sensitized, or maybe just someone who had been on dialysis for 10 years. It's important that UNOS put rules in place so that anyone who gets a kidney, even a multiorgan transplant candidate, gets a kidney because they really need it.

Dr Berns: Now, the circumstances. Somebody might have chronic kidney disease or acute kidney injury and liver disease, and they may or may not need a transplant. They may recover their kidney function if it's acute kidney injury, or it may be chronic kidney disease that doesn't yet require a transplant. I guess that's part of the problem. What are the proposed rules? What's going to change?

Dr Reese: Multiple things will change. These are changes that have been vetted through an extensive public comment period. Hopefully, stakeholders have had a chance to give their opinion on whether this is the right thing to do. First, a transplant nephrologist will be involved in the evaluation of this multiorgan transplant recipient, the person who wants to get a liver and a kidney. The transplant team will have to request that a kidney also be allocated, and then the job of that transplant nephrologist is to confirm that there is either chronic kidney disease or acute kidney disease where the injury is severe and sustained.

So, for the chronic kidney disease requirement, the way that it's currently stated is that the disease has been documented for 90 days and that there has been a glomerular filtration rate (GFR) < 30 mL/min/1.73 m2 around the time of registration. There are a lot of details to it, but the main piece is that a transplant nephrologist is involved in certifying that true chronic kidney disease exists.

Dr Berns: Which is not the case now.

Dr Reese: Exactly. Nothing like that is required now. The second piece is very different. Let's say that a patient got a liver transplant alone. It doesn't really matter whether or not they went through this process beforehand. They got a liver transplant alone. If, in the first posttransplant year, their GFR goes below 20 mL/min/1.73 m2 or they need dialysis, they would get priority to get a kidney transplant after the liver has been done.

Dr Berns: I see, but only in the first year post–liver transplant.

Dr Reese: That's right. They're calling it a safety net. We've never seen anything like this before. In some sense, I think this type of concession was necessary to get everyone on board with approving this more restrictive pathway to multiorgan transplantation.

Dr Berns: So, there are specific GFR criteria now, there is a requirement for a transplant nephrologist to weigh in on the decision, and there is a safety net.

Dr Reese: Yes.

Dr Berns: When do you think this will happen?

Dr Reese: We have a board meeting coming up. It's possible that it will be approved this year. Then there are going be some programming requirements that they've scoped out. So it might be a year from now, but don't hold me to that. Most important, after that, they have to make sure that there is a plan to gather data on how this goes. The expectation is that it's possible for the number of simultaneous liver-kidney transplants to stay the same. If it were to go up a lot, I think that might be cause for concern.

Dr Berns: The hope is that it reduces the number of kidneys that are transplanted, right?

Dr Reese: I think some people hope that, but whether or not that happens, the most important thing is that now we have more fairness, we have more efficiency, and we have objective medical criteria. If you get a kidney transplant in any circumstance, you'll at least have demonstrated that there is a need for it.

Dr Berns: You don't think this will put people who are on a kidney-only transplant list at a disadvantage?

Dr Reese: I hope not. I mean, I do feel strongly that there are certain groups who are very disadvantaged in the sense that we should think of them as people who are in a very tough spot, and they deserve some extra allocation priority. For me, I've come to the conclusion that those groups include children, people with a lot of antibodies against donors, and people who have been on the waiting list for a very long time.

Dr Berns: Good. Thanks, Peter, for helping to clarify this.

Dr Reese: Thanks very much.

Dr Berns: We'll stay tuned. Hopefully we'll hear more about this over the next year or so. This is Jeffrey Berns, editor-in-chief of Medscape Nephrology, from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. Thanks for listening.

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