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Simultaneous Liver–Kidney Allocation: Let's Not Make Perfect the Enemy of Good

Wadei et al (1) provided a thoughtful response to the paper, “Simultaneous Liver–Kidney Allocation Policy: A Proposal to Optimize Appropriate Utilization of Scare Resources” (2). Before responding directly to their concern, it is important to place this policy proposal in the proper context. Currently there are no medical eligibility criteria for simultaneous liver–kidney (SLK) allocation. In fact, SLK allocation represents the archetype of the problem of multiorgan allocation in that it disregards the Organ Procurement and Transplantation Network’s Final Rule and subjects patients to a two-class system for those who receive priority access regardless of need and those who do not. This approach results in the syphoning off of kidneys that may have been allocated to children and others in need and giving them to patients awaiting liver transplantation who potentially may not need them. The SLK working group realized that the only path forward was through good faith compromise and designing an allocation policy that could be monitored prospectively and modified as new data suggested needed changes.