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

Venkatesh K Ariyamuthu1, Xingxing S Cheng2, Benjamin Hippen3

  • 1Division of Nephrology, University of Arizona, Tucson, AZ.

Transplantation
|March 12, 2025
PubMed

Insights

The 2018 adult Heart Allocation Policy revision increased simultaneous heart-kidney transplants (SHKT) but also raised mortality and graft failure rates. Policy adjustments are needed to improve outcomes and ensure transplant equity.

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.
Abstract

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