The Effect of Acuity Circle Policy of Simultaneous Liver and Kidney Transplant in the United States

Author Type(s)

Faculty, Resident/Fellow

Document Type

Abstract

Publication Date

2022

DOI

10.1002/hep.32697

Journal Title

Hepatology

Department

Surgery

Second Department

Medicine

Abstract

Background: New deceased donor liver allocation policy was implemented on February 4, 2020 using an acuity circle (AC)-based model to reduce waitlist mortality for liver transplant. The effect of AC policy remains unknown in simultaneous liver and kidney transplant (SLKT). The aim of this study was to assess the effect of AC-policy on SLKT outcomes, regarding waitlist mortality, transplant probability, and post-transplant outcomes. Methods: We analyzed data from the United Network for Organ Sharing (UNOS) between 2017 and 2021. Adult SLKT candidates were included in this study. Two periods were defined: Pre-AC (August 10, 2017 to February 3, 2020) and Post-AC (February 4, 2020 to December 31, 2021). The 90-day waitlist outcomes were analyzed with a competing risk analysis. Multivariable cox regression analyses were performed to evaluate post-transplant survival analysis and propensity score matching was also performed to adjust covariates of recipients between Pre-AC and Post-AC. P<0.05 was taken as statistically significant. Results: A total of 4,692 patients listed for SLKT were included in the analysis (post-AC 2176 vs pre-AC 2516). Compared to the pre-AC era, the post-AC era had more Caucasians (post-AC 64% vs pre-AC 60%), fewer African Americans (post-AC 8.7% vs pre-AC 12%), higher median MELD score (post-AC 24 vs pre-AC 23, P<0.001), and less percentage of MELD exception (post-AC 4.8% vs pre-AC 7.0%, P=0.001). The most common primary diagnosis was alcohol-related liver disease, which was more common in the post-AC era (post-AC 38% vs pre-AC 33%). The cumulative incidence of 90-day waitlist mortality was same between two eras (P=0.36). The probability of transplant significantly increased in the post-AC era (P<0.001). On multivariable analysis, the post-AC was not associated with 90-day waitlist mortality (sub-distribution hazard ratio [sHR] 0.77; 95% CI 0.55-1.08, P=0.13), but significant higher 90-day probability of transplant (sHR 1.52; 95% CI 1.32-1.88, P<0.001). For post-transplant outcomes, one-year patient survival, liver graft survival, and kidney graft survival were comparable between two eras in non-matched and matched cohorts. In Cox regression analysis, post-AC era was not an independent risk factor for one-year mortality, liver graft failure, and kidney graft failure. Conclusion: This study showed that AC liver allocation increased transplant probability of adult SLKT candidates without decreasing waitlist mortality, post-transplant patient survival, and liver and kidney graft survival. (Figure Presented).

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