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Impact of the 2018 United States Heart Allocation System on Patients Waitlisted for Combined Heart and Kidney Transplantation
Yeahwa Hong, Nicholas R. Hess, Luke A. Ziegler, Gavin W. Hickey, Jessica H. Huston, Michael A. Mathier, Dennis M. McNamara, Mary E. Keebler, David J. Kaczorowski.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Objective: This study evaluates the impact of the 2018 heart allocation system on outcomes of patients waitlisted for combined heart and kidney (CHK) transplantation.
Methods: The UNOS registry was queried to identify adults listed for CHK from 5/5/2015 to 3/31/2020. The cohort was stratified as before and after the heart allocation policy change, where both groups had an equal follow-up period of 2 years. The primary outcomes were rates of transplantation and de-listing due to death or clinical deterioration within 2 years of waitlisting, and secondary outcomes included rates of post-transplant survival and complications.
Results: A total of 871 patients were analyzed in this study. Of these, 504 patients (57.9%) were listed after the policy change. The new policy group had a significantly higher rate of transplantation with shorter waitlist time (46 vs 123 days, p<0.001) (Figure) with a sub-hazard ratio of 1.44 (95% CI 1.21-1.71, p<0.001). Competing-risk regression demonstrated a comparable risk of de-listing between the two groups (p=0.054). Furthermore, the recipients of CHK in both groups had comparable 2-year post-transplant survival (p=0.1302). The rates of post-transplant complications, including renal failure requiring dialysis, stroke, permanent pacemaker, hospital length of stay, and acute rejection, were also similar between the groups (Table).
Conclusions: This study demonstrates decreased waitlist time with increased incidence of CHK transplantation in the new policy era. Despite the improved CHK transplantability in the new allocation system, survival on the waitlist and post-transplant outcomes are comparable to the previous 3-tier system.

Table. Post-transplant outcomes stratified by before and after heart allocation policy change
Old Policy (n=214)New Policy (n=325)p-value
Renal failure requiring dialysis67 (31.6%)113 (34.9%)0.43
Stroke11 (5.2%)10 (3.1%)0.22
Permanent pacemaker3 (1.4%)5 (1.5%)0.90
Hospital length of stay (days)23 [16-34]22 [14-35]0.62
Treated acute rejection within 1st year6 (2.8%)15 (4.6%)0.29


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