Current OPTN/UNOS policy prioritizes candidates seeking a simultaneous liver kidney (SLK) transplant before pediatric and adult transplant candidates who are listed only for a kidney (“kidney alone candidates”) when the liver candidate and the deceased donor are in the same Donation Service Area (DSA). Unlike kidney alone allocation, in SLK allocation, the kidney is not allocated based on medical criteria assessing the kidney function of the candidate. Instead, geographic proximity between the liver-kidney candidate and the donor is the single factor for allocating the kidney with the liver. Organ procurement organizations (OPOs) are not required to allocate the kidney with the liver to a regional SLK candidate, although they have the discretion to do so.

The Kidney Transplantation Committee (“the Committee”), has identified several problems with this current policy:

• The current policy for SLK allocation is counter to requirements in the OPTN Final Rule (“Final Rule”) specifying that organ allocation policies be based on sound medical judgment and standardized criteria.

• The lack of medical criteria results in the allocation of high quality kidneys to liver candidates who may regain renal function after liver transplant and decreased access for kidney alone candidates who would otherwise be highly prioritized in deceased donor kidney allocation.

• The lack of consistency for regional SLK allocation has been a tremendous concern for the liver transplant community, as deceased donor liver allocation prioritizes candidates with a certain medical urgency status or Model End Stage Liver Disease Score (MELD) score or Pediatric End Stage Liver Disease (PELD) score for regional allocation but regional liver-kidney allocation is not required for these candidates.

In order to provide more clarity and consistency in the rules for liver-kidney allocation, the Committee is proposing a second round of public comment on this proposal which consists of the following:

• Establish medical eligibility criteria for adult candidates seeking an SLK transplant.

• Provide greater clarity for the rules around liver-kidney allocation and fix the inconsistency that exists between deceased donor liver allocation policy and liver-kidney allocation policy.

• Establish a “safety net” (new match classification priority on the kidney alone waiting list) for liver recipients with continued dialysis dependency or kidney dysfunction in the first year after liver transplant as an added element to address concerns about limitations associated with the SLK medical eligibility criteria.

This proposal is the result of two consensus conferences and two rounds of public comment and incorporates feedback from the OPTN/UNOS Board of Directors, 11 OPTN/UNOS regions, several professional transplant societies, patient advocacy groups, and various OPTN/UNOS committees. The proposal is intended to further the OPTN strategic goal to “provide equity in access to transplants” by addressing the objective to “establish clearer rules for allocation of multiple organs to a single candidate, especially liver-kidney candidates.”