The Final Rule in a Bind: What We Are Learning From Suboptimal Simultaneous Heart-Kidney Outcomes and Potential...

Area of Science:

• Transplantation Medicine
• Organ Allocation Policy
• Nephrology

Background:

• The 2018 revision of the adult Heart Allocation Policy (aHAP) in the US increased simultaneous heart-kidney transplants (SHKT).
• Criticism of the aHAP includes its failure to improve post-transplant survival or reduce waitlist mortality for SHKT recipients.
• High-quality kidneys are utilized in SHKT under the current policy.

Purpose of the Study:

• To evaluate the impact of the 2018 aHAP revision on SHKT outcomes.
• To compare post-transplant survival and graft failure rates before and after the policy change.
• To assess adverse kidney outcomes following SHKT under the revised policy.

Main Methods:

• Analysis of 1549 SHKT cases from the Organ Procurement and Transplantation Network (2015-2021).
• Assessment of 1-year post-transplant outcomes, including graft failure and adverse kidney events.
• Propensity score-matching to compare cohorts before (pre-October 2018) and after (post-October 2018) policy implementation.

Main Results:

• The post-aHAP implementation period showed significantly increased mortality (HR 1.62) and all-cause graft failures for both heart (HR 1.59) and kidney (HR 1.39).
• One-year incidence of adverse kidney outcomes was 6.8% under the new aHAP versus 5.3% previously among survivors (P=0.33).

Conclusions:

• The revised aHAP has led to suboptimal outcomes for SHKT recipients.
• Potential negative impacts on kidney-alone transplant candidates warrant consideration.
• Regular monitoring and potential revision of SHKT policies are essential to meet equity and utility goals.