Transplantation · 2024
The Final Rule in a Bind: What We Are Learning From Suboptimal Simultaneous Heart-Kidney Outcomes and Potential Solutions to the Problem.
СтатьяПоддержка исследования: вне правительства СШАНазвание и аннотация: Перевод в очереди
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Ariyamuthu Venkatesh K, Cheng Xingxing S, Hippen Benjamin, Bloom Roy D, Acharya Deepak, Araj Faris, Gungor Ahmet B, Alhamad Tarek, Singh Neeraj, Anand Prince M, Gupta Gaurav, Akalin Enver, Molnar Miklos Z, Mete Mutlu, Ayvaci Mehmet U S, Doshi Mona, Tanriover Bekir
Аннотация
BACKGROUND: The 2018 revision of the adult Heart Allocation Policy (aHAP) led to a notable increase in the rate of simultaneous heart-kidney transplants (SHKT) in the United States. However, this policy has faced criticism for its inability to enhance post-transplant survival rates or decrease mortality among SHKT recipients on the waitlist, although high-quality kidneys are used.
METHODS: We analyzed data from the Organ Procurement and Transplantation Network, covering 1549 SHKT cases from 2015 to 2021. The study assessed 1-y post-transplant outcomes, including all-cause heart and kidney graft failures and adverse kidney outcomes such as end-stage kidney disease, significantly reduced kidney function or the need for retransplantation. Using a propensity score-matching approach, we compared 2 cohorts: patients treated before and after the policy implementation in October 2018.
RESULTS: The multivariable Cox proportional hazard models indicated a significant increase in mortality (hazard ratio [HR] 1.62; 95% confidence interval [CI], 1.10-2.37) and all-cause graft failures for both heart (HR 1.59; 95% CI, 1.08-2.33) and kidney (HR 1.39; 95% CI, 1.03-1.85) during the period after the new aHAP implementation. One year post-transplant, the incidence of adverse kidney outcomes was 6.8% under the new aHAP compared with 5.3% in the previous period among survivors ( P = 0.33).
CONCLUSIONS: The suboptimal outcomes of SHKT under the new aHAP, alongside its potential impacts on kidney-alone transplant candidates, suggest a need for regular monitoring of SHKT policies. This is crucial to ensure that the intentions of the Final Rule regarding equity and utility are effectively met.
METHODS: We analyzed data from the Organ Procurement and Transplantation Network, covering 1549 SHKT cases from 2015 to 2021. The study assessed 1-y post-transplant outcomes, including all-cause heart and kidney graft failures and adverse kidney outcomes such as end-stage kidney disease, significantly reduced kidney function or the need for retransplantation. Using a propensity score-matching approach, we compared 2 cohorts: patients treated before and after the policy implementation in October 2018.
RESULTS: The multivariable Cox proportional hazard models indicated a significant increase in mortality (hazard ratio [HR] 1.62; 95% confidence interval [CI], 1.10-2.37) and all-cause graft failures for both heart (HR 1.59; 95% CI, 1.08-2.33) and kidney (HR 1.39; 95% CI, 1.03-1.85) during the period after the new aHAP implementation. One year post-transplant, the incidence of adverse kidney outcomes was 6.8% under the new aHAP compared with 5.3% in the previous period among survivors ( P = 0.33).
CONCLUSIONS: The suboptimal outcomes of SHKT under the new aHAP, alongside its potential impacts on kidney-alone transplant candidates, suggest a need for regular monitoring of SHKT policies. This is crucial to ensure that the intentions of the Final Rule regarding equity and utility are effectively met.