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

Abstract

The safety-net policy for kidney-after-lung transplants (KALT), implemented in the U.S. on 6/29/2023, allows Lung Transplant (LT) candidates with acute kidney injury (AKI), with or without underlying chronic kidney disease (CKD), to undergo LT alone with 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 (UNOS) registry, we identified patients listed for SLKT or KALT through 12/31/2024. KALT was classified as early (≤365 days post-LT) or late (>365 days post-LT). The cohort was also divided into safety-net or pre-safety-net eras. The primary outcome variable was the risk of delisting from the kidney transplant waitlist from deterioration or death, and the secondary outcome was 1-year post-Lung transplant mortality. Among 1,941 patients, 300 (15.4%), 135 (7%), and 1506 (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<0.001). Listing in the safety-net era was associated with decreased odds of being delisted from the KT (adjusted Odds Ratio, aOR 0.34, 95% CI 0.19-0.60, p<0.001). SLKT had a higher post-LT mortality (22.1% vs 3.2% vs 0%, p<0.001) and post-KT mortality (21.5% vs 12.5% vs 7.57%, p<0.001) at 1-year, compared to early- and late-KALT. Since the safety net policy's introduction, SLKT has decreased while 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.