Background: Kidney after liver (KAL) transplantation is the best therapeutic option for patients with ESRD after liver transplantation (OLT). Current allocation policies create a safety net, prioritizing kidneys to patients remaining in renal failure following OLT. Unfortunately, the effects of these policies on balancing utility with limited resources has not been analyzed. In this study we compared survival, death censored graft survival (DCGS) and rejection among matched-paired kidney transplant alone (KTA) vs. KAL recipients.

Methods: The UNOS database was queried for adult KAL recipients from 1988-2015 and compared to their paired KTA recipients. After exclusion criteria (other transplant before OLT, transplants other than KAL, and inability to calculate KDPI), 796 pairs were identified. Log-rank test evaluated Kaplan-Meier survival distributions and matched-pair analysis. Multivariate analysis of recipient characteristics evaluated outcome differences.

Results: Recipient demographics were comparable. Mean time from OLT and KTA was 8.5 years. Overall 1, 5 and 10-year survival was inferior after KAL (92%, 75%, 55%) compared to KTA (95%, 85%, 73%, p<0.001). Similarly, DCGS was lower after KAL (93%, 60%, 23%) than KTA (96%, 67%, 31%, p<0.001). Kidney rejection was similar in both groups (p=0.82). Stratified by KDPI, survival and DCGS were reduced in KAL compared to KTA for KDPI<85% (p<0.001), however, for those with KDPI ≥85% no significant differences in survival (p=0.94) or DCGS (p=0.25) were observed. KAL patients with KDPI <85% graft half-life was shorter by 1.1 years than KTA (p<0.01). For KDPI <85%, matched-pair analysis revealed reduced patient survival by 1.32 years and graft survival by 0.64 years in KAL recipients versus KTA (p<0.01). Multivariate analysis identified diabetes and age as significant risk factors associated with shorter survival and DCGS in KAL recipients. There was no significant difference in survival or DCGS between KAL patients with a KDPI <85% and >85%.

Conclusions: Our study revealed superior survival and DCGS in KTA recipients when compared to KAL recipients with KDPI <85%, associated with diabetes and increasing age. From a utilitarian perspective, patients who underwent a KTA with a KDPI <85% received the greatest long-term benefit and should receive special consideration as allocation policies continue to develop. Since KAL mortality and DCGS are equivalent regardless of KDPI, allocation policies for KAL should shift focus from kidney quality to facilitating access of care.

CITATION INFORMATION: Eerhart M., Reyes J., Danobeitia J., Zitur L., Chlebeck P., Fernandez L. Kidney after Liver Transplant: A Matched Pair Analysis Am J Transplant. 2017;17 (suppl 3).

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