Multi-organ transplantation involving the kidney: Eligibility and controversies in allocation

Both acute renal failure and chronic kidney disease are highly prevalent among non-renal organ transplant populations and contribute to increased morbidity and premature mortality in these patients. Criteria for kidney transplantation with simultaneous pancreas kidney (SPK), and simultaneous liver kidney (SLK) transplantation are well-defined by the United Network of Organ Sharing (UNOS), but criteria for simultaneous heart kidney transplantation (SHK) and combined lung-kidney transplantation (CLK) remain undefined, with most centers adopting their own criteria. While prioritization should continue to be given to those patients in urgent need in whom SHK and CLK are appropriate options, care must be taken to avoid kidney transplant in those candidates who have a chance of renal recovery and in those with poor-transplant survival. Future initiatives must focus on universally agreed upon guidelines for eligibility of SHK and CLK. A "safety net" policy that exists for SLK candidates is also needed for potential SKH and CLK candidates to optimize allocation of kidneys. As stewards of a limited resource, the governing organizations, as well as the transplant community, must continue to strive for fairness and beneficence in organ allocation, considering the obligation to the kidney alone recipient, particularly because the high-quality kidneys for multi-organ transplants are prioritized over pediatric and young adult kidney alone recipients who otherwise have a long expected post-transplant survival.