LIVER TRANSPLANTATION 20:1017–1018, 2014
To Whom Goes the Kidney? Jayme E. Locke University of Alabama at Birmingham, Birmingham, AL Received July 2, 2014; accepted July 3, 2014.
See Article on Page 1034 Deceased donor organs in the United States continue to be a scarce resource, and the debate over the equity of kidney allocation to liver transplant candidates with renal insufficiency remains unresolved. The increasing prevalence of acute and chronic renal dysfunction among liver transplant candidates across the backdrop of an ever-growing kidney transplant waiting list has created and continues to create a set of competing priorities and a seemingly circular debate about how best to optimize a scare resource.1-3 In one corner are data demonstrating increased waiting-list mortality among end-stage liver disease patients with comorbid renal disease; this suggests that simultaneous liver-kidney transplantation (SLK) should be the norm for liver candidates with renal impairment.2,4-6 In the other corner are data suggesting that upward of 80% of liver transplant recipients on renal replacement therapy (RRT) for fewer than 30 days go on to recover renal function after transplantation, and this indicates that at least some kidneys transplanted as part of SLK are unnecessary.7 To whom then goes the kidney, the liver transplant candidate with renal impairment or the kidney transplant candidate? There is little debate about the necessity for SLK among end-stage renal disease patients with decompensated cirrhosis because these patients have no hope of recovering renal function and would not survive kidney transplantation alone; this establishes a clear role for SLK.8 Therefore, how we frame the discussion about SLK is critical. The debate is not whether to eliminate SLK; rather, the focus of the debate should be the subset of liver transplant candidates with recent renal impairment (