Declining outcomes in simultaneous liver-kidney transplantation in the MELD era: Ineffective usage of renal allografts

Jayme E. Locke, Daniel Warren, Andrew L. Singer, Dorry Segev, Christopher E. Simpkins, Warren R. Maley, Robert A. Montgomery, Gabriel Danovitch, Andrew M Cameron

Research output: Contribution to journalArticle

Abstract

BACKGROUND. When the United Network for Organ Sharing changed its algorithm for liver allocation to the model for end-stage liver disease (MELD) system in 2002, highest priority shifted to patients with renal insufficiency as a major component of their end-stage liver disease. An unintended consequence of the new system was a rapid increase in the number of simultaneous liver-kidney transplants (SLK) being performed yearly. METHODS. Adult recipients of deceased donor liver transplants (LT, n=19,137), kidney transplants (n=33,712), and SLK transplants (n=1,032) between 1987 and 2006 were evaluated based on United Network for Organ Sharing data. Recipients were stratified by donor subgroup, MELD score, pre- versus post-MELD era, and length of time on dialysis. Matched-control analyses were performed, and graft and patient survival were analyzed by Kaplan-Meier and Cox proportional hazards analyses. RESULTS. MELD era outcomes demonstrate a decline in patient survival after SLK. Using matched-control analysis, we are unable to demonstrate a benefit in the SLK cohort compared with LT, despite the fact that higher quality allografts are being used for SLK. Subgroup analysis of the SLK cohort did demonstrate an increase in overall 1-year patient and liver graft survival only in those patients on long-term dialysis (≥3 months) compared with LT (84.5% vs. 70.8%, P=0.008; hazards ratio 0.57 [95% CI 0.34, 0.95], P=0.03). CONCLUSION. These findings suggest that SLK may be overused in the MELD era and that current prioritization of kidney grafts to those liver failure patients results in wasting of limited resources.

Original languageEnglish (US)
Pages (from-to)935-942
Number of pages8
JournalTransplantation
Volume85
Issue number7
DOIs
StatePublished - Apr 2008

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End Stage Liver Disease
Liver Transplantation
Kidney Transplantation
Allografts
Transplants
Kidney
Liver
Graft Survival
Dialysis
Tissue Donors
Information Dissemination
Liver Failure
Renal Insufficiency

Keywords

  • Allocation
  • MELD
  • Outcomes
  • Simultaneous liver-kidney transplantation

ASJC Scopus subject areas

  • Transplantation
  • Immunology

Cite this

Declining outcomes in simultaneous liver-kidney transplantation in the MELD era : Ineffective usage of renal allografts. / Locke, Jayme E.; Warren, Daniel; Singer, Andrew L.; Segev, Dorry; Simpkins, Christopher E.; Maley, Warren R.; Montgomery, Robert A.; Danovitch, Gabriel; Cameron, Andrew M.

In: Transplantation, Vol. 85, No. 7, 04.2008, p. 935-942.

Research output: Contribution to journalArticle

Locke, Jayme E. ; Warren, Daniel ; Singer, Andrew L. ; Segev, Dorry ; Simpkins, Christopher E. ; Maley, Warren R. ; Montgomery, Robert A. ; Danovitch, Gabriel ; Cameron, Andrew M. / Declining outcomes in simultaneous liver-kidney transplantation in the MELD era : Ineffective usage of renal allografts. In: Transplantation. 2008 ; Vol. 85, No. 7. pp. 935-942.
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abstract = "BACKGROUND. When the United Network for Organ Sharing changed its algorithm for liver allocation to the model for end-stage liver disease (MELD) system in 2002, highest priority shifted to patients with renal insufficiency as a major component of their end-stage liver disease. An unintended consequence of the new system was a rapid increase in the number of simultaneous liver-kidney transplants (SLK) being performed yearly. METHODS. Adult recipients of deceased donor liver transplants (LT, n=19,137), kidney transplants (n=33,712), and SLK transplants (n=1,032) between 1987 and 2006 were evaluated based on United Network for Organ Sharing data. Recipients were stratified by donor subgroup, MELD score, pre- versus post-MELD era, and length of time on dialysis. Matched-control analyses were performed, and graft and patient survival were analyzed by Kaplan-Meier and Cox proportional hazards analyses. RESULTS. MELD era outcomes demonstrate a decline in patient survival after SLK. Using matched-control analysis, we are unable to demonstrate a benefit in the SLK cohort compared with LT, despite the fact that higher quality allografts are being used for SLK. Subgroup analysis of the SLK cohort did demonstrate an increase in overall 1-year patient and liver graft survival only in those patients on long-term dialysis (≥3 months) compared with LT (84.5{\%} vs. 70.8{\%}, P=0.008; hazards ratio 0.57 [95{\%} CI 0.34, 0.95], P=0.03). CONCLUSION. These findings suggest that SLK may be overused in the MELD era and that current prioritization of kidney grafts to those liver failure patients results in wasting of limited resources.",
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T1 - Declining outcomes in simultaneous liver-kidney transplantation in the MELD era

T2 - Ineffective usage of renal allografts

AU - Locke, Jayme E.

AU - Warren, Daniel

AU - Singer, Andrew L.

AU - Segev, Dorry

AU - Simpkins, Christopher E.

AU - Maley, Warren R.

AU - Montgomery, Robert A.

AU - Danovitch, Gabriel

AU - Cameron, Andrew M

PY - 2008/4

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N2 - BACKGROUND. When the United Network for Organ Sharing changed its algorithm for liver allocation to the model for end-stage liver disease (MELD) system in 2002, highest priority shifted to patients with renal insufficiency as a major component of their end-stage liver disease. An unintended consequence of the new system was a rapid increase in the number of simultaneous liver-kidney transplants (SLK) being performed yearly. METHODS. Adult recipients of deceased donor liver transplants (LT, n=19,137), kidney transplants (n=33,712), and SLK transplants (n=1,032) between 1987 and 2006 were evaluated based on United Network for Organ Sharing data. Recipients were stratified by donor subgroup, MELD score, pre- versus post-MELD era, and length of time on dialysis. Matched-control analyses were performed, and graft and patient survival were analyzed by Kaplan-Meier and Cox proportional hazards analyses. RESULTS. MELD era outcomes demonstrate a decline in patient survival after SLK. Using matched-control analysis, we are unable to demonstrate a benefit in the SLK cohort compared with LT, despite the fact that higher quality allografts are being used for SLK. Subgroup analysis of the SLK cohort did demonstrate an increase in overall 1-year patient and liver graft survival only in those patients on long-term dialysis (≥3 months) compared with LT (84.5% vs. 70.8%, P=0.008; hazards ratio 0.57 [95% CI 0.34, 0.95], P=0.03). CONCLUSION. These findings suggest that SLK may be overused in the MELD era and that current prioritization of kidney grafts to those liver failure patients results in wasting of limited resources.

AB - BACKGROUND. When the United Network for Organ Sharing changed its algorithm for liver allocation to the model for end-stage liver disease (MELD) system in 2002, highest priority shifted to patients with renal insufficiency as a major component of their end-stage liver disease. An unintended consequence of the new system was a rapid increase in the number of simultaneous liver-kidney transplants (SLK) being performed yearly. METHODS. Adult recipients of deceased donor liver transplants (LT, n=19,137), kidney transplants (n=33,712), and SLK transplants (n=1,032) between 1987 and 2006 were evaluated based on United Network for Organ Sharing data. Recipients were stratified by donor subgroup, MELD score, pre- versus post-MELD era, and length of time on dialysis. Matched-control analyses were performed, and graft and patient survival were analyzed by Kaplan-Meier and Cox proportional hazards analyses. RESULTS. MELD era outcomes demonstrate a decline in patient survival after SLK. Using matched-control analysis, we are unable to demonstrate a benefit in the SLK cohort compared with LT, despite the fact that higher quality allografts are being used for SLK. Subgroup analysis of the SLK cohort did demonstrate an increase in overall 1-year patient and liver graft survival only in those patients on long-term dialysis (≥3 months) compared with LT (84.5% vs. 70.8%, P=0.008; hazards ratio 0.57 [95% CI 0.34, 0.95], P=0.03). CONCLUSION. These findings suggest that SLK may be overused in the MELD era and that current prioritization of kidney grafts to those liver failure patients results in wasting of limited resources.

KW - Allocation

KW - MELD

KW - Outcomes

KW - Simultaneous liver-kidney transplantation

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