Simultaneous liver kidney transplantation: A medical decision analysis

Background: The use of simultaneous liver kidney transplantation has increased dramatically. When the liver and kidney are available from the same deceased donor, what is the best decision? There are two allocation options. In the combined allocation, both organs are allocated to a liver failure (end-stage liver disease [ESLD]) patient on dialysis leaving an end-stage renal disease (ESRD) patient on dialysis. In split allocation, the liver is allocated to the liver failure patient on dialysis and the kidney to the patient with ESRD. Methods: A computerized medical decision analysis was performed using published US survival data. The two options were compared by examining differences in projected quality-adjusted life years (QALYs). Results: Combined allocation was the best strategy (+0.806 QALYs) if liver transplant recipients on dialysis have proportionately worse survival compared with kidney failure alone patients on dialysis. However, because some patients with hepatorenal syndrome recover kidney function post-liver transplant alone (LTA), a second analysis incorporated the possibilities of being dialysis free. If the chance of recovery of renal function is 50% rather than 0%, the decision reversed. Here, the split allocation provided 1.02 more total QALYs than the combined allocation. Conclusions: This study demonstrates that simultaneous liver kidney transplantation is an excellent strategy in most patients with both ESLD and ESRD. However, allocating a kidney to a patient with ESLD, who has the potential to be dialysis free without a kidney transplant, does not maximize overall outcomes when all patients are considered.