• Author
    Hedwig Zappacosta
  • Discovery PI

    Abbas Ardehali

  • Project Co-Author

  • Abstract Title

    Evaluating the 2023 Safety-Net Kidney Policy: Eligibility, Timing, and Outcomes of Heart Transplant Recipients in the United States

  • Discovery AOC Petal or Dual Degree Program

    Medical Education Leadership & Scholarship

  • Abstract

    Purpose

    In 2023, the Organ Procurement and Transplantation Network implemented a safety-net kidney policy, granting priority kidney allocation to heart transplant recipients with persistent renal dysfunction. This policy represented an effort to refine donor kidney allocation, especially in the context of simultaneous heart-kidney transplant (SHKT). This study describes outcomes since policy implementation.

    Methods

    The United Network for Organ Sharing database was queried for all heart transplant recipients between July 2023 and November 2025. Recipients were stratified into safety-net kidney (SNK) non-eligible, SNK eligible, and SHKT cohorts. Predictors of SNK eligibility were identified using a logistic regression model. The primary outcome was 1-year survival between SNK eligible and SHKT recipients. Secondary outcomes included 90-day and 6-month survival and acute rejection within one year.

    Results

    Of 8,684 heart transplant recipients, 8.9% (n=771) underwent SHKT, and 4.2% (n=335) of isolated heart transplant were SNK eligible. Predictors of SNK eligibility included pre-transplant dialysis (adjusted odds ratio 2.23, p=0.01) and extracorporeal membrane oxygenation (adjusted odds ratio 1.13, p=0.01). 1-year survival was similar between SNK eligible and SHKT recipients (97.6% vs 94.6%, p=0.91), including amongst SNK eligible recipients who received a kidney transplant (100.0% vs 94.6%, p=0.07).  There were no differences in 90-day or 6-month survival. Rejection within one year was higher in the SNK eligible cohort than the SHKT cohort (12.5% vs 4.4%, p<0.001). 

    Conclusion

    The safety-net pathway confers comparable 1-year survival to simultaneous heart-kidney transplant However, longer follow-up is warranted, particularly given the higher prevalence of rejection within one year amongst safety-net eligible recipients.

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