Abstract: FR-OR087
Kidney Wait-Listing After Liver Transplant in the Safety Net Era: Evidence for Policy Reconsideration
Session Information
- The Changing Landscape of Kidney Transplantation: Clinical Innovation, Outcomes, and Health Policy
October 23, 2026 | Location: Mile High Ballroom 4A, Convention Center
Abstract Time: 05:10 PM - 05:20 PM
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Randhawa, Divya, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
- Eckhoff, Devin, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
- Pavlakis, Martha, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
- Sureshkumar, Kalathil K., Allegheny General Hospital, Pittsburgh, Pennsylvania, United States
- Chopra, Bhavna, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
Background
The 2017 OPTN Safety Net policy prioritizes kidney transplantation (KT) for liver transplant (LT) recipients with persistent renal dysfunction listed within 60–365 days post-LT. While intended to preserve timely KT, it may incentivize precautionary early Kidney after Liver (eKAL) listing and discourage delisting. We evaluated waitlist utilization and clinical relevance of eKAL listing under this policy
Methods
We analyzed patients listed for KT within 1 year of LT (eKAL) between 2014-2024 using OPTN data. Outcomes included listing volume, transplant rate, time from activation to KT, waitlist status, inactivity reasons and cumulative waitlist burden (yearly June 1 snapshots)
Results
Among 2,278 eKAL listings, yearly listing increased from 43 (2014) to 466 (2024) with predominantly inactive candidates at 1 year (Table). Cumulative waitlist size increased from 16 (2014) to 910 (2024), driven primarily by inactive candidates (2024: 779 inactive vs 131 active) (Figure). Inactivity was mostly due to incomplete workup and temporarily too sick status; however, a substantial proportion were temporarily too well, suggesting absence of immediate transplant need. Patients requiring KT underwent rapid transplantation once active. Median time from first active status to KT declined from 56 days in 2014 to 10 days in 2024 (Table).
Conclusion
Under the Safety Net policy, eKAL generates a large persistently inactive waitlist including patients without current transplant indication reflecting inefficient resource utilization. This may incentivize precautionary listing of ineligible patients while increasing administrative and care-coordination burden on transplant programs, although preserving timely KT for those who ultimately need it.
eKAL waitlist for 2014-2024. Outcomes for candidates listed in 2024 may be underestimated due to incomplete follow up as OPTN data were available till April 2025
Yearly eKAL Waitlist