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Tejedor M, Neria F, De La Rosa G, Almohalla Álvarez C, Padilla M, Boscà Robledo A, Fundora Suárez Y, Sánchez-Bueno F, Gómez-Bravo MA, Berenguer M. Women Are Also Disadvantaged in Accessing Transplant Outside the United States: Analysis of the Spanish Liver Transplantation Registry. Transpl Int 2024; 37:12732. [PMID: 38773987 PMCID: PMC11106452 DOI: 10.3389/ti.2024.12732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/16/2024] [Indexed: 05/24/2024]
Abstract
Sex inequities in liver transplantation (LT) have been documented in several, mostly US-based, studies. Our aim was to describe sex-related differences in access to LT in a system with short waiting times. All adult patients registered in the RETH-Spanish Liver Transplant Registry (2000-2022) for LT were included. Baseline demographics, presence of hepatocellular carcinoma, cause and severity of liver disease, time on the waiting list (WL), access to transplantation, and reasons for removal from the WL were assessed. 14,385 patients were analysed (77% men, 56.2 ± 8.7 years). Model for end-stage liver disease (MELD) score was reported for 5,475 patients (mean value: 16.6 ± 5.7). Women were less likely to receive a transplant than men (OR 0.78, 95% CI 0.63, 0.97) with a trend to a higher risk of exclusion for deterioration (HR 1.17, 95% CI 0.99, 1.38), despite similar disease severity. Women waited longer on the WL (198.6 ± 338.9 vs. 173.3 ± 285.5 days, p < 0.001). Recently, women's risk of dropout has reduced, concomitantly with shorter WL times. Even in countries with short waiting times, women are disadvantaged in LT. Policies directed at optimizing the whole LT network should be encouraged to guarantee a fair and equal access of all patients to this life saving resource.
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Affiliation(s)
| | - Fernando Neria
- Universidad Francisco de Vitoria, Pozuelo de Alarcón, Spain
| | | | | | | | | | | | | | | | - Marina Berenguer
- Hepatology—Liver Transplantation Unit, IIS La Fe and CIBER-EHD, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
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2
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Yi NJ, Kim J, Hong SY, Kang HG. Combined liver-kidney transplantation in pediatric patients. Pediatr Transplant 2024; 28:e14666. [PMID: 38059323 DOI: 10.1111/petr.14666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 09/16/2023] [Accepted: 11/21/2023] [Indexed: 12/08/2023]
Abstract
Combined liver-kidney transplantation (CLKT) is a surgical procedure that involves transplanting both liver and kidney organs. There are two types of CLKT: simultaneous liver-kidney transplantation (smLKT) and sequential LKT (sqLKT). CLKT accounts for a small percentage of liver transplantations (LTs), particularly in pediatric cases. Nevertheless, the procedure has demonstrated excellent outcomes, with high survival rates and lower rejection rates. The main indications for CLKT in pediatric patients differ somewhat from that in adults, in which end-stage kidney disease after LT is the major indication. In children, congenital diseases are common reason for performing CLKT; the examples of such diseases include autosomal recessive polycystic kidney disease with congenital hepatic fibrosis which equally affects both organs, and primary hyperoxaluria type 1, a primary liver disease leading kidney failure. The decision between smLKT or sqLKT depends on the dominant organ failure, the specific pathophysiology, and available organ sources. However, there remain significant surgical and societal challenges surrounding CLKT. Innovations in pharmacology and genetic engineering have decreased the necessity for CLKT in early-diagnosed cases without portal hypertension or kidney replacement therapy. Nonetheless, these advancements are not universally accessible. Therefore, decision-making algorithms should be crafted, considering region-specific organ allocation systems and prevailing medical environments.
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Affiliation(s)
- Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jiyoung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Su Young Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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3
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Predictors of Kidney Delayed Graft Function and Its Prognostic Impact following Combined Liver-Kidney Transplantation: A Recent Single-Center Experience. J Clin Med 2022; 11:jcm11102724. [PMID: 35628851 PMCID: PMC9146237 DOI: 10.3390/jcm11102724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 12/04/2022] Open
Abstract
Combined liver−kidney transplantation (CLKT) improves patient survival among liver transplant recipients with renal dysfunction. However, kidney delayed graft function (kDGF) still represents a common and challenging complication that can negatively impact clinical outcomes. This retrospective study analyzed the incidence, potential risk factors, and prognostic impact of kDGF development following CLKT in a recently transplanted cohort. Specifically, 115 consecutive CLKT recipients who were transplanted at our center between January 2015 and February 2021 were studied. All transplanted kidneys received hypothermic pulsatile machine perfusion (HPMP) prior to transplant. The primary outcome was kDGF development. Secondary outcomes included the combined incidence and severity of developing postoperative complications; development of postoperative infections; biopsy-proven acute rejection (BPAR); renal function at 1, 3, 6, and 12 months post-transplant; and death-censored graft and patient survival. kDGF was observed in 37.4% (43/115) of patients. Multivariable analysis of kDGF revealed the following independent predictors: preoperative dialysis (p = 0.0003), lower recipient BMI (p = 0.006), older donor age (p = 0.003), utilization of DCD donors (p = 0.007), and longer delay of kidney transplantation after liver transplantation (p = 0.0003). With a median follow-up of 36.7 months post-transplant, kDGF was associated with a significantly increased risk of developing more severe postoperative complication(s) (p < 0.000001), poorer renal function (particularly at 1 month post-transplant, p < 0.000001), and worse death-censored graft (p = 0.00004) and patient survival (p = 0.0002). kDGF may be responsible for remarkable negative effects on immediate and potentially longer-term clinical outcomes after CLKT. Understanding the important risk factors for kDGF development in CLKT may better guide recipient and donor selection(s) and improve clinical decisions in this increasing group of transplant recipients.
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4
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Samoylova ML, Wegermann K, Shaw BI, Kesseli SJ, Au S, Park C, Halpern SE, Sanoff S, Barbas AS, Patel YA, Sudan DL, Berg C, McElroy LM. The Impact of the 2017 Kidney Allocation Policy Change on Simultaneous Liver-Kidney Utilization and Outcomes. Liver Transpl 2021; 27:1106-1115. [PMID: 33733560 PMCID: PMC8380035 DOI: 10.1002/lt.26053] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/10/2021] [Accepted: 03/08/2021] [Indexed: 12/11/2022]
Abstract
Historically in the United States, kidneys for simultaneous liver-kidney transplantation (SLKT) candidates were allocated with livers, prioritizing SLKT recipients over much of the kidney waiting list. A 2017 change in policy delineated renal function criteria for SLKT and implemented a safety net for kidney-after-liver transplantation. We compared the use and outcomes of SLKT and kidney-after-liver transplant with the 2017 policy. United Network for Organ Sharing Standard Transplant Analysis and Research files were used to identify adults who received liver transplantations (LT) from August 10, 2007 to August 10, 2012; from August 11, 2012 to August 10, 2017; and from August 11, 2017 to June 12, 2019. LT recipients with end-stage renal disease (ESRD) were defined by dialysis requirement or estimated glomerular filtration rate <25. We evaluated outcomes and center-level, regional, and national practice before and after the policy change. Nonparametric cumulative incidence of kidney-after-liver listing and transplant were modeled by era. A total of 6332 patients received SLKTs during the study period; fewer patients with glomerular filtration rate (GFR) ≥50 mL/min underwent SLKT over time (5.8%, 4.8%, 3.0%; P = 0.01 ). There was also less variability in GFR at transplant after policy implementation on center and regional levels. We then evaluated LT-alone (LTA) recipients with ESRD (n = 5408 from 2012-2017; n = 2321 after the policy). Listing for a kidney within a year of LT increased from 2.9% before the policy change to 8.8% after the policy change, and the rate of kidney transplantation within 1 year increased from 0.7% to 4% (P < 0.001). After the policy change, there was no difference in patient survival rates between SLKT and LTA among patients with ESRD. Implementation of the 2017 SLKT policy change resulted in reduced variability in SLKT recipient kidney function and increased access to deceased donor kidney transplantation for LTA recipients with kidney disease without negatively affecting outcomes.
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Affiliation(s)
- Mariya L. Samoylova
- Department of Surgery, Division of Gastroenterology, Duke University Hospital, Durham, NC
| | - Kara Wegermann
- Department of Medicine, Division of Gastroenterology, Duke University Hospital, Durham, NC
| | - Brian I. Shaw
- Department of Surgery, Division of Gastroenterology, Duke University Hospital, Durham, NC
| | - Samuel J. Kesseli
- Department of Surgery, Division of Gastroenterology, Duke University Hospital, Durham, NC
| | - Sandra Au
- Duke University School of Medicine, Durham, NC
| | | | | | - Scott Sanoff
- Division of Nephrology, Department of Medicine, Duke Unviersity Hospital, Durham, NC
| | - Andrew S. Barbas
- Department of Surgery, Division of Gastroenterology, Duke University Hospital, Durham, NC
| | - Yuval A. Patel
- Division of Hepatology, Department of Medicine, Duke Unviersity Hospital, Durham, NC
| | - Debra L. Sudan
- Department of Surgery, Division of Gastroenterology, Duke University Hospital, Durham, NC
| | - Carl Berg
- Division of Nephrology, Department of Medicine, Duke Unviersity Hospital, Durham, NC
| | - Lisa M. McElroy
- Department of Surgery, Division of Gastroenterology, Duke University Hospital, Durham, NC
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5
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Vincenzi P, Gaynor JJ, Chen LJ, Figueiro J, Morsi M, Selvaggi G, Tekin A, Vianna R, Ciancio G. No Benefit of Prophylactic Surgical Drainage in Combined Liver and Kidney Transplantation: Our Experience and Review of the Literature. Front Surg 2021; 8:690436. [PMID: 34322515 PMCID: PMC8311022 DOI: 10.3389/fsurg.2021.690436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/08/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Contrasting results have emerged from limited studies investigating the role of prophylactic surgical drainage in preventing wound morbidity after liver and kidney transplantation. This retrospective study analyzes the use of surgical drain and the incidence of wound complications in combined liver and kidney transplantation (CLKTx). Methods: A total of 55 patients aged ≥18 years were divided into two groups: the drain group (D) (n = 35) and the drain-free group (DF) (n = 20). Discretion to place a drain was based exclusively on surgeon preference. All deceased donor kidneys were connected to the LifePort Renal Preservation Machine® prior to transplantation, in both simultaneous and delayed technique of implantation of the renal allograft. The primary outcome was the development of superficial/deep wound complications during the study follow-up. Secondary outcomes included the development of delayed graft function (DGF) of the transplanted kidney, primary non-function (PNF) and early allograft dysfunction (EAD) of the transplanted liver, graft failure, graft and patient survival, overall post-operative morbidity rate and length of hospital stay. Results: With a median follow-up of 14.4 months after transplant, no difference in the incidence of superficial/deep wound complications, except for hematomas, in collections size, intervention rate, PNF, EAD, graft failure and patient survival, was observed between the 2 groups. Significantly lower level of platelets, higher INR values, DGF, morbidity rates and length of hospital stay were reported post-operatively in the D group. Pre-operative hypoalbuminemia and longer CIT were included in the propensity score for receiving a drain and were associated with a significantly higher rate of developing a hematoma post-transplant. Conclusions: Absence of the surgical drain did not appear to adversely affect wound morbidity compared to the prophylactic use of drains in renal transplant patients during CLKTx.
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Affiliation(s)
- Paolo Vincenzi
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States.,Division of Liver and Intestinal Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Jeffrey J Gaynor
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Linda J Chen
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Jose Figueiro
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Mahmoud Morsi
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States.,Division of Liver and Intestinal Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Gennaro Selvaggi
- Division of Liver and Intestinal Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Akin Tekin
- Division of Liver and Intestinal Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Rodrigo Vianna
- Division of Liver and Intestinal Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Gaetano Ciancio
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States.,Department of Urology, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
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6
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Bouari S, Rijkse E, Metselaar HJ, van den Hoogen MWF, IJzermans JNM, de Jonge J, Polak WG, Minnee RC. A comparison between combined liver kidney transplants to liver transplants alone: A systematic review and meta-analysis. Transplant Rev (Orlando) 2021; 35:100633. [PMID: 34098490 DOI: 10.1016/j.trre.2021.100633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/09/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Since the introduction of the Model for End-stage Liver disease criteria in 2002, more combined liver kidney transplants are performed. Until 2017, no standard allocation policy for combined liver kidney transplant (CLKT) was available and each transplant center decided eligibility for CLKT or liver transplant alone (LTA) on a case-by-case basis. The aim of this systematic review was to compare the clinical outcomes of CLKT compared to LTA in patients with renal dysfunction. METHODS Databases were systematically searched for studies published between January 2010 and March 2021. Outcomes were expressed as risk ratios and pooled with a random-effects model. The primary outcome was patient survival. RESULTS Four studies were included. No differences were observed for mortality risk at 1 year (risk ratio (RR) 1.03 [confidence interval (CI) 0.97-1.09], 3 years (RR 1.06 [CI 0.99-1.13]) and 5 years (RR 1.08 [CI 0.98-1.19]). The risk of graft loss was similar in the first year (RR 1.10 [CI 0.93-1.30], while 3-year risk of graft loss was significantly lower in CLKT patients (RR 1.15 [CI 1.08-1.24]). CONCLUSIONS CLKT has similar short-term graft and patient survival as LTA in patients with renal dysfunction. More data is needed to decide from which KDIGO stage patients benefit the most from CLKT.
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Affiliation(s)
- Sarah Bouari
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC University Transplant Institute, Rotterdam, the Netherlands
| | - Elsaline Rijkse
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC University Transplant Institute, Rotterdam, the Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus MC University Transplant Institute, Rotterdam, the Netherlands
| | - Martijn W F van den Hoogen
- Department of Internal Medicine, Section of Nephrology and Transplantation, Erasmus MC University Transplant Institute, Rotterdam, the Netherlands
| | - Jan N M IJzermans
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC University Transplant Institute, Rotterdam, the Netherlands
| | - Jeroen de Jonge
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC University Transplant Institute, Rotterdam, the Netherlands
| | - Wojciech G Polak
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC University Transplant Institute, Rotterdam, the Netherlands
| | - Robert C Minnee
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC University Transplant Institute, Rotterdam, the Netherlands.
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Thongprayoon C, Kaewput W, Petnak T, O’Corragain OA, Boonpheng B, Bathini T, Vallabhajosyula S, Pattharanitima P, Lertjitbanjong P, Qureshi F, Cheungpasitporn W. Impact of Palliative Care Services on Treatment and Resource Utilization for Hepatorenal Syndrome in the United States. MEDICINES 2021; 8:medicines8050021. [PMID: 34065828 PMCID: PMC8150700 DOI: 10.3390/medicines8050021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/01/2021] [Accepted: 05/11/2021] [Indexed: 12/16/2022]
Abstract
Background: This study aimed to determine the rates of inpatient palliative care service use and assess the impact of palliative care service use on in-hospital treatments and resource utilization in hospital admissions for hepatorenal syndrome. Methods: Using the National Inpatient Sample, hospital admissions with a primary diagnosis of hepatorenal syndrome were identified from 2003 through 2014. The primary outcome of interest was the temporal trend and predictors of inpatient palliative care service use. Logistic and linear regression was performed to assess the impact of inpatient palliative care service on in-hospital treatments and resource use. Results: Of 5571 hospital admissions for hepatorenal syndrome, palliative care services were used in 748 (13.4%) admissions. There was an increasing trend in the rate of palliative care service use, from 3.3% in 2003 to 21.1% in 2014 (p < 0.001). Older age, more recent year of hospitalization, acute liver failure, alcoholic cirrhosis, and hepatocellular carcinoma were predictive of increased palliative care service use, whereas race other than Caucasian, African American, and Hispanic and chronic kidney disease were predictive of decreased palliative care service use. Although hospital admission with palliative care service use had higher mortality, palliative care service was associated with lower use of invasive mechanical ventilation, blood product transfusion, paracentesis, renal replacement, vasopressor but higher DNR status. Palliative care services reduced mean length of hospital stay and hospitalization cost. Conclusion: Although there was a substantial increase in the use of palliative care service in hospitalizations for hepatorenal syndrome, inpatient palliative care service was still underutilized. The use of palliative care service was associated with reduced resource use.
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Affiliation(s)
- Charat Thongprayoon
- Department of Medicine, Mayo Clinic, Division of Nephrology and Hypertension, Rochester, MN 55905, USA;
- Correspondence: (C.T.); (W.K.); (T.P.); (P.P.); (W.C.)
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand
- Correspondence: (C.T.); (W.K.); (T.P.); (P.P.); (W.C.)
| | - Tananchai Petnak
- Division of Pulmonary and Pulmonary Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Correspondence: (C.T.); (W.K.); (T.P.); (P.P.); (W.C.)
| | - Oisin A. O’Corragain
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA 19140, USA;
| | - Boonphiphop Boonpheng
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA;
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85719, USA;
| | - Saraschandra Vallabhajosyula
- Section of Interventional Cardiology, Department of Medicine, Division of Cardiovascular Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA;
| | - Pattharawin Pattharanitima
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
- Correspondence: (C.T.); (W.K.); (T.P.); (P.P.); (W.C.)
| | - Ploypin Lertjitbanjong
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA;
| | - Fawad Qureshi
- Department of Medicine, Mayo Clinic, Division of Nephrology and Hypertension, Rochester, MN 55905, USA;
| | - Wisit Cheungpasitporn
- Department of Medicine, Mayo Clinic, Division of Nephrology and Hypertension, Rochester, MN 55905, USA;
- Correspondence: (C.T.); (W.K.); (T.P.); (P.P.); (W.C.)
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8
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Ekser B, Goggins WC. Delayed kidney transplantation in combined liver-kidney transplantation. Curr Opin Organ Transplant 2021; 26:153-159. [PMID: 33595980 DOI: 10.1097/mot.0000000000000858] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW To review the impact of delayed kidney transplantation approach in combined (simultaneous) liver-kidney transplantation (CLKT). RECENT FINDINGS CLKT offers a life-saving procedure for patients with both end-stage liver disease and chronic kidney disease or prolonged acute kidney injury. It is the most common multiorgan transplant procedure in the US accounting for 9-10% of all liver transplants performed. The number of CLKT has also been increasing in other countries with a better understanding of hepato-renal syndrome. US is the only country which implemented a national allocation policy for CLKT in 2017. Due to the different physiological needs of liver and kidney allografts immediately after transplantation, delayed kidney transplantation approach in CLKT has been introduced for the first time by the Indiana Group, naming it as 'the Indiana Approach'. Over the years, many other groups in the US and in Europe published better outcomes in CLKT using the delayed kidney transplantation approach with the support of hypothermic machine perfusion. SUMMARY Several groups have shown that delayed kidney transplantation in CLKT is a safe procedure with better outcomes in graft(s) and patient survival.
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Affiliation(s)
- Burcin Ekser
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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9
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Kriss M, Biggins SW. Evaluation and selection of the liver transplant candidate: updates on a dynamic and evolving process. Curr Opin Organ Transplant 2021; 26:52-61. [PMID: 33278150 DOI: 10.1097/mot.0000000000000829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Although conceptually unchanged, the evaluation and selection of the liver transplant candidate has seen significant recent advances. Expanding criteria for transplant candidacy, improved diagnostics for risk stratification and advances in prognostic models have paralleled recent changes in allocation and distribution that require us to revisit core concepts of candidate evaluation and selection while recognizing its now dynamic and continuous nature. RECENT FINDINGS The liver transplant evaluation revolves around three interrelated themes: candidate selection, donor selection and transplant outcome. Introduction of dynamic frailty indices, bariatric surgery at the time of liver transplant in obese patients and improved therapies and prognostic tools for hepatobiliary malignancy have transformed candidate selection. Advances in hypothermic organ preservation have improved outcomes in marginal donor organs. Combined with expansion of hepatitis C virus positive and split donor organs, donor selection has become an integral part of candidate evaluation. In addition, with liver transplant for acute alcohol-related hepatitis now widely performed and increasing recognition of acute-on-chronic liver failure, selection of critically ill patients is refining tools to balance futility versus utility. SUMMARY Advances in liver transplant candidate evaluation continue to transform the evaluation process and require continued incorporation into our clinical practice amidst a dynamic backdrop of demographic and policy changes.
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Affiliation(s)
- Michael Kriss
- Division of Gastroenterology & Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Scott W Biggins
- Division of Gastroenterology and Hepatology
- Center for Liver Investigation Fostering discovEry (C-LIFE), University of Washington, Seattle, Washington, USA
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10
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Adani GL, Pravisani R, Tulissi P, Isola M, Calini G, Terrosu G, Boscutti G, Avital I, Ekser B, Baccarani U. Hypothermic machine perfusion can safely prolong cold ischemia time in deceased donor kidney transplantation. A retrospective analysis on postoperative morbidity and graft function. Artif Organs 2021; 45:516-523. [PMID: 33210745 DOI: 10.1111/aor.13858] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/29/2020] [Accepted: 11/02/2020] [Indexed: 12/16/2022]
Abstract
In deceased donor kidney transplantation (KT), a prolonged cold ischemia time (CIT) is a negative prognostic factor for KT outcome, and the efficacy of hypothermic machine perfusion (HMP) in prolonging CIT without any additional hazard is highly debated. We conducted a retrospective study on a cohort of 154 single graft deceased donor KTs, in which a delayed HMP, after a preliminary period of static cold storage (SCS), was used to prolong CIT for logistic reasons. Primary outcomes were postoperative complications as well as 1 year graft survival and function. 73 cases (47.4%) were managed with HMP and planned KT, while 81 (52.6%) with SCS and urgent KT. The median CIT in HMP group and SCS group was 29 hour:57 minutes [27-31 hour:45 minutes] and 11 hour:25 minutes [9-14 hour:30 minutes], respectively (P < .001). The period of SCS in the HMP group was significantly shorter than in the SCS group (10 vs. 11 hour:25 minutes, P = .02) as well as the prevalence of expanded criteria donors was significantly higher (43.8% vs. 18.5%, P < .01). After propensity score matching for these two baseline characteristics, the HMP and SCS groups showed comparable outcomes in terms of delayed graft function, vascular, and urologic complications, infections, and episodes of graft rejection. At 1 year follow-up, serum creatinine levels were comparable between the groups. Therefore, the use of HMP to prolong the CIT and convert KT into a planned procedure seemed to have an adequate safety profile, with outcomes comparable to KT managed as an urgent procedure and a CIT nearly three time shorter.
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Affiliation(s)
- Gian Luigi Adani
- Liver-Kidney Transplantation Unit - Department of Medicine, University of Udine, Udine, Italy
| | - Riccardo Pravisani
- Liver-Kidney Transplantation Unit - Department of Medicine, University of Udine, Udine, Italy
| | | | - Miriam Isola
- Division of Medical Statistic - Department of Medicine, University of Udine, Udine, Italy
| | - Giacomo Calini
- Liver-Kidney Transplantation Unit - Department of Medicine, University of Udine, Udine, Italy
| | - Giovanni Terrosu
- Liver-Kidney Transplantation Unit - Department of Medicine, University of Udine, Udine, Italy
| | | | - Itzhak Avital
- Department of Surgery A, Soroka University Medical Center, Beer Sheva, Israel
| | - Burcin Ekser
- Division of Transplant Surgery - Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Umberto Baccarani
- Liver-Kidney Transplantation Unit - Department of Medicine, University of Udine, Udine, Italy
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11
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Ekser B, Halazun KJ, Petrowsky H, Balci D. Liver transplantation and hepatobiliary surgery in 2020. Int J Surg 2020; 82S:1-3. [PMID: 32698032 PMCID: PMC7369005 DOI: 10.1016/j.ijsu.2020.07.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 10/28/2022]
Affiliation(s)
- Burcin Ekser
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Karim J Halazun
- Department of Surgery, Division of Liver Transplantation and Hepatobiliary Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Deniz Balci
- Department of Surgery and Liver Transplantation Unit, Ankara University School of Medicine, Ankara, Turkey
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Ekser B, Goggins WC, Fridell JA, Mihaylov P, Mangus RS, Lutz AJ, Soma D, Ghabril MS, Lacerda MA, Powelson JA, Kubal CA. Impact of Recipient Age in Combined Liver-Kidney Transplantation: Caution Is Needed for Patients ≥70 Years. Transplant Direct 2020; 6:e563. [PMID: 33062847 PMCID: PMC7531750 DOI: 10.1097/txd.0000000000001011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/01/2020] [Indexed: 11/26/2022] Open
Abstract
Elderly recipients (≥70 y) account for 2.6% of all liver transplants (LTs) in the United States and have similar outcomes as younger recipients. Although the rate of elderly recipients in combined liver-kidney transplant (CLKT) is similar, limited data are available on how elderly recipients perform after CLKT. METHODS We have previously shown excellent outcomes in CLKT using delayed kidney transplant (Indiana) Approach (mean kidney cold ischemia time = 53 ± 14 h). Between 2007 and 2018, 98 CLKTs were performed using the Indiana Approach at Indiana University (IU) and the data were retrospectively analyzed. Recipients were subgrouped based on their age: 18-45 (n = 16), 46-59 (n = 34), 60-69 (n = 40), and ≥70 years (n = 8). RESULTS Overall, more elderly patients received LT at IU (5.2%) when compared nationally (2.6%). The rate of elderly recipients in CLKT at IU was 8.2% (versus 2% Scientific Registry of Transplant Recipient). Recipient and donor characteristics were comparable between all age groups except recipient age and duration of dialysis. Patient survival at 1 and 3 years was similar among younger age groups, whereas patient survival was significantly lower in elderly recipients at 1 (60%) and 3 years (40%) (P = 0.0077). Control analyses (replicating Scientific Registry of Transplant Recipient's survival stratification: 18-45, 46-64, ≥65 y) showed similar patient survival in all age groups. CONCLUSIONS Although LT can be safely performed in elderly recipients, extreme caution is needed in CLKT due to the magnitude of operation.
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Affiliation(s)
- Burcin Ekser
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - William C. Goggins
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Jonathan A. Fridell
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Plamen Mihaylov
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Richard S. Mangus
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Andrew J. Lutz
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Daiki Soma
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Marwan S. Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Marco A. Lacerda
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - John A. Powelson
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Chandrashekhar A. Kubal
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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13
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Shanker A, Bashashati M. An invited commentary on "Ekser B, Contreras AG, Andraus W, Taner T. Current status of combined liver-kidney transplantation. Int J Surg. 2020 Feb 19. pii: S1743-9191(20)30171-0. doi: 10.1016/j.ijsu.2020.02.008.". Int J Surg 2020; 77:57-58. [PMID: 32200060 DOI: 10.1016/j.ijsu.2020.03.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/15/2020] [Indexed: 01/15/2023]
Affiliation(s)
- Aaron Shanker
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Mohammad Bashashati
- Division of Gastroenterology, Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA.
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14
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Invited commentary on "Current status of combined liver-kidney transplantation. Int J Surg 2020; Epub ahead of print". Int J Surg 2020; 77:34-35. [PMID: 32200052 DOI: 10.1016/j.ijsu.2020.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/15/2020] [Indexed: 11/23/2022]
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