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• W2893368204 abstract "SEE ARTICLE ON PAGE 1570 Potential conflict of interest: Nothing to report. “Hard cases make bad law.” The legal maxim comes to mind as we read the interesting review by Shekhtman et al.1 on simultaneous dual‐kidney liver transplantation (DKLT) in the United States. The first thing that strikes us is the very rarity of the procedure. Over the decade examined by the authors, a total of 22 DKLTs were performed in the United States. The vast majority of transplant centers never attempted a single DKLT. A total of 10 centers performed just 1 DKLT, 3 centers performed 2 DKLTs, and just 2 centers completed 3 DKLTs. DKLTs quite literally have been unique experiences, and as such, it is not possible to adequately capture bias by indication. It is not clear what factors were considered in the decision to move forward with DKLT, and thus, it is difficult to provide general guidance from such hard cases. This may go some ways in explaining the differences seen in the current review with the more favorable results reported by Di Laudo et al.2 Although limited by short median follow‐up, this Italian study showed acceptable graft and patient outcomes in DKLT when compared with combined liver and single‐kidney transplantation, despite a baseline higher kidney donor profile index (KDPI) in the DKLT group. Notably, this single‐center case‐control study included a detailed algorithm and specific recipient and donor criteria for the selection of potential DKLT candidates. Although still a small study, their rate of DKLT (4 over 40 months) was at least an order of magnitude higher than even the busiest DKLT centers included in the present study. Since the introduction of the Model for End‐Stage Liver Disease (MELD)–based liver allocation policy in 2002, the rates of simultaneous liver‐kidney transplantation (SLKT) have increased from 2%‐3% to 8%‐9% of all liver transplants.3 Although a critical option for liver transplant candidates with advanced kidney dysfunction, this practice remains controversial because SLKTs divert deceased donor kidneys, often of high quality, away from the kidney transplant candidate pool. In response to this controversy, the United Network for Organ Sharing (UNOS)/Organ Procurement and Transplantation Network introduced a new policy in 2017 to more clearly define medical criteria for SLKT with a goal to engender more consistent and equitable allocation; however, the impact of this policy remains uncertain.4 In light of long waiting times and organ shortage, multiple strategies have been employed to expand the kidney donor pool. Dual‐kidney transplant from donors whose kidneys would otherwise be discarded is an attractive option. Indeed, although there is considerable heterogeneity in reports of the practice, dual‐kidney transplantation has been shown to result in comparable survival and function when compared with those receiving single‐kidney transplantation from expanded criteria donors.5 In liver transplant candidates with advanced kidney dysfunction, 3 other means of expanding the donor pool should be included in the discussion as well: single extended criteria donor kidneys, increased use of hepatitis C virus (HCV)–positive organs, and living kidney donation. Continued efforts to optimize the successful use of single‐kidney extended criteria donors in SLKT represents an alternative to the increased procedural complexity of DKLT. Although various transplant groups have demonstrated increased mortality in recipients of SLKT when they received kidney grafts from donors with higher KDPI, Ekser et al. demonstrated acceptable SLKT outcomes in their higher KDPI kidney group when they followed a delayed approach to kidney implantation and the use of hypothermic pulsatile machine perfusion prior to transplant.6 We also endorse acceptance of HCV‐positive organs. A recent analysis of the UNOS database performed by our group demonstrated that many good‐quality, HCV‐positive kidneys are being discarded even when the livers from these same donors are being transplanted successfully.8 HCV‐positive organs represent an important opportunity to expand the kidney donor pool in the SLKT population. Finally, consideration in select cases should be given to forgoing SLKT in favor of liver transplant alone with a plan for kidney transplant later, if necessary. A recent UNOS policy change established a “safety net” to give priority to liver transplant patients who require kidney transplant within a year after liver transplant. In liver transplant recipients with hepatorenal syndrome, this provides the opportunity for recovery of native renal function without consigning them to several years of dialysis if renal dysfunction persists. There may also be select patients with established good living kidney donors where the graft survival advantage of the living kidney transplant may outweigh the benefits of SLKT with an extended criteria single or dual kidney. Despite the discouraging results presented by Shekhtman et al. in this issue, we are not prepared to say that there is never a role for DKLT. It is possible to conceive of a case with an extraordinary set of donor and recipient circumstances where DKLT is the best option for the patient. Given the alternatives available, however, we suspect that such hard cases will remain appropriately rare." @default.
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• W2893368204 date "2018-11-01" @default.
• W2893368204 modified "2023-09-26" @default.
• W2893368204 title "Simultaneous Liver and Kidney Transplantation: How to Expand the Kidney Donor Pool?" @default.
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• W2893368204 doi "https://doi.org/10.1002/lt.25348" @default.
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