Dataset Information

Impact of medical eligibility criteria and OPTN policy on simultaneous liver kidney allocation and utilization.

ABSTRACT:

Background

Organ Procurement and Transplantation Network (OPTN) implemented medical eligibility and safety-net policy on 8/10/17 to optimize simultaneous liver-kidney (SLK) utilization. We examined impact of this policy on SLK listings and number of kidneys used within 1-yr. of receiving liver transplantation (LT) alone.

Methods and results

OPTN database (08/10/14-06/12/20) on adults (N = 66 709) without previous transplant stratified candidates to listings for SLK or LT alone with pre-LT renal dysfunction at listing (eGFR < 30 mL/min or on dialysis). Outcomes were compared for pre (08/10/14-08/09/17) vs. post (08/10/17-06/12/20) policy era. SLK listings decreased in post vs. pre policy era (8.7% vs. 9.6%; P < .001), with 22% reduced odds of SLK listing in the postpolicy era, with a decrease in all OPTN regions except regions 6 and 8, which showed an increase. Among LT-alone recipients with pre-LT renal dysfunction (N = 3272), cumulative 1-year probability was higher in post vs. prepolicy period for dialysis (5.6% vs. 2.3%; P < .0001), KT listing (11.4% vs. 2.0%; P < .0001), and KT (3.7% vs. .25%; P < .0001). Sixty-seven (2.4%) kidneys were saved in post policy era, with 18.1%, 16.6%, 4.3%, and 2.9% saving from regions 7, 2, 11, and 1, respectively.

Conclusion

Medical eligibility and safety-net OPTN policy resulted in decreased SLK use and improved access to LT alone among those with pre-LT renal dysfunction. Although decreased in postpolicy era, regional variation of SLK listings remains. In spite of increased use of KT within 1-year of receiving LT alone under safety net, less number of kidneys were used without impact on patient survival in postpolicy era.

SUBMITTER: Singal AK

PROVIDER: S-EPMC9930183 | biostudies-literature | 2022 Jul

REPOSITORIES: biostudies-literature

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Publications

Impact of medical eligibility criteria and OPTN policy on simultaneous liver kidney allocation and utilization.

Singal Ashwani K AK Kuo Yong-Fang YF Kwo Paul P Mahmud Nadim N Sharma Pratima P Nadim Mitra K MK

Clinical transplantation 20220601 7

<h4>Background</h4>Organ Procurement and Transplantation Network (OPTN) implemented medical eligibility and safety-net policy on 8/10/17 to optimize simultaneous liver-kidney (SLK) utilization. We examined impact of this policy on SLK listings and number of kidneys used within 1-yr. of receiving liver transplantation (LT) alone.<h4>Methods and results</h4>OPTN database (08/10/14-06/12/20) on adults (N = 66 709) without previous transplant stratified candidates to listings for SLK or LT alone wit ...[more]

PMID: 35543138

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Project description:ObjectivesIn 2017, the World Health Organization (WHO) medical eligibility criteria (MEC) for contraception category for intramuscular depot medroxyprogesterone acetate (DMPA-IM) was changed from MEC category 1 to 2 for women at high risk of HIV acquisition. We assessed the impact of communicating this category change among women in the Evidence for Contraceptive options and HIV Outcomes (ECHO) trial.Study designECHO was conducted in eSwatini, Kenya, South Africa and Zambia. Women were randomized (1:1:1) to DMPA-IM, levonorgestrel (LNG) implant or copper intrauterine device (Cu IUD). We compared the hazards of DMPA-IM discontinuation and assessed sexual behavior and DMPA-IM satisfaction before and after MEC category change.ResultsIn DMPA-IM users there was a decrease in the hazards of discontinuation after the MEC change (hazard ratio 0.37; 95% CI = 0.26-0.52, p < 0.001). No evidence of an effect of the MEC change was observed in sexual behaviour outcomes. There was some evidence of an increase in disatisfaction with DMPA-IM immediately after the MEC change, with the odds of women reporting a higher score (more dissatisfied) increasing by 1.38 compared with before the MEC change (95% CI = 1.11-1.72).ConclusionsWhile counseling on possible theoretical risks associated with contraceptive methods in the MEC is an important medical ethical standard, in this study it did not adversely impact continuation or sexual behavior, while there was some evidence on increase in dissatisfaction. There is however a need to monitor how changes in MEC categories are implemented.ImplicationsAlthough we found no evidence in this analysis of an effect of the MEC change on any of the sexual behavioral outcomes among women after the change in category, it is still an important medical ethical standard to counsel on possible theoretical risks associated with contraceptive methods. Given the challenges of translating research findings to guidelines and further to counseling messages, evaluation of clinical guidelines implementation is necessary to understand the effects of implementation and to monitor both intended impacts and unintended consequences.

Project description:Simultaneous liver-kidney transplantation (SLKT) is increasingly common in the United States. However, little is known about the renal-related outcomes following SLKT, which are essential to maximize the health of these allografts. We examined the factors impacting renal function following SLKT. This is an observational multicenter cohort study from the US Multicenter SLKT Consortium consisting of recipients of SLKT aged ≥18 years of transplantations performed between February 2002 and June 2017 at 6 large US centers in 6 different United Network for Organ Sharing regions. The primary outcome was incident post-SLKT stage 4-5 chronic kidney disease (CKD) defined as <30 mL/minute/1.73 m2 or listing for kidney transplant. The median age of the recipients (n = 570) was 58 years (interquartile range, 51-64 years), and 37% were women, 76% were White, 33% had hepatitis C virus infection, 20% had nonalcoholic steatohepatitis (NASH), and 23% had alcohol-related liver disease; 68% developed ≥ stage 3 CKD at the end of follow-up. The 1-year, 3-year, and 5-year incidence rates of post-SLKT stage 4-5 CKD were 10%, 12%, and 16%, respectively. Pre-SLKT diabetes mellitus (hazard ratio [HR], 1.45; 95% CI, 1.00-2.15), NASH (HR, 1.58; 95% CI, 1.01-2.45), and delayed kidney graft function (HR, 1.72; 95% CI, 1.10-2.71) were the recipient factors independently associated with high risk, whereas the use of tacrolimus (HR, 0.44; 95% CI, 0.22-0.89) reduced the risk. Women (β = -6.22 ± 2.16 mL/minute/1.73 m2 ; P = 0.004), NASH (β = -7.27 ± 3.27 mL/minute/1.73 m2 ; P = 0.027), and delayed kidney graft function (β = -7.25 ± 2.26 mL/minute/1.73 m2 ; P = 0.007) were independently associated with low estimated glomerular filtration rate at last follow-up. Stage 4-5 CKD is common after SLKT. There remains an unmet need for personalized renal protective strategies, specifically stratified by sex, diabetes mellitus, and liver disease, to preserve renal function among SLKT recipients.

Dataset Information

Impact of medical eligibility criteria and OPTN policy on simultaneous liver kidney allocation and utilization.

Background

Methods and results

Conclusion

Publications

Impact of medical eligibility criteria and OPTN policy on simultaneous liver kidney allocation and utilization.

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