Early Trends After Safety Net Policy Introduction for Kidney After Lung Transplantation

The safety net policy for kidney after lung transplant (KALT), implemented in the United States on June 29, 2023, allows lung transplant (LT) candidates with acute kidney injury, with or without underlying chronic kidney disease, to undergo LT alone allowing the potential for renal recovery. This may decrease the need to list for simultaneous lung-kidney transplant (SLKT).

What was the change in kidney transplant (KT) and LT practice patterns after the safety net policy? Are the outcomes of KALT better than SLKT?

Using the United Nations Organ Sharing registry, we identified patients listed for SLKT or KALT through December 31, 2024. KALT was classified as early (≤ 365 days post-LT) or late (> 365 days post-LT). The cohort was also divided into safety-net and pre-safety net eras. The primary outcome variable was the risk of delisting from the KT waitlist from deterioration or death, and the secondary outcome was 1-year post-LT mortality.

Among 1,941 patients, 300 (15.4%), 135 (7%), and 1,506 (77.6%) were listed for SLKT, early-KALT, and late-KALT, respectively. Since the safety net policy, there has been a decrease in the proportion of SLKT and an increase in early KALT, with a shorter KT waitlist time (94 vs 330 days; P < .001). Listing during the safety net era was associated with decreased odds of being delisted from KT (adjusted OR, 0.34; 95% CI, 0.19-0.60; P < .001). SLKT had a higher post-LT mortality (22.1% vs 3.2% vs 0%; P < .001) and post-KT mortality (21.5% vs 12.5% vs 7.57%; P < .001) at 1 year compared with early- and late-KALT, respectively.

Our results show that since the safety net policy's introduction, SLKT has decreased, whereas early-KALT has increased, with better short-term outcomes and reduced delisting; however, survivorship bias may influence these findings. Prospective studies are needed to further compare SLKT and KALT outcomes in the current era.