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Nilles KM, Levitsky J. Current and Evolving Indications for Simultaneous Liver Kidney Transplantation. Semin Liver Dis 2021; 41:308-320. [PMID: 34130337 DOI: 10.1055/s-0041-1729969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This review will discuss the etiologies of kidney disease in liver transplant candidates, provide a historical background of the prior evolution of simultaneous liver-kidney (SLK) transplant indications, discuss the current indications for SLK including Organ Procurement and Transplantation Network policies and Model for End Stage Liver Disease exception points, as well as provide an overview of the safety net kidney transplant policy. Finally, the authors explore unanswered questions and future research needed in SLK transplantation.
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Affiliation(s)
- Kathy M Nilles
- Division of Gastroenterology and Hepatology, Department of Medicine, MedStar Georgetown Transplant Institute, Georgetown University School of Medicine, Washington, District of Columbia
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Department of Medicine, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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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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Tariq R, Singal AK. Management of Hepatorenal Syndrome: A Review. J Clin Transl Hepatol 2020; 8:192-199. [PMID: 32832400 PMCID: PMC7438356 DOI: 10.14218/jcth.2020.00011] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/23/2020] [Accepted: 05/08/2020] [Indexed: 12/11/2022] Open
Abstract
Acute kidney injury (AKI) occurs frequently in patients with cirrhosis, and hepatorenal syndrome (HRS) is second most common etiology of AKI after volume responsible pre-renal etiology. AKI in these patients negatively impacts pre- and post-transplant patient survival and healthcare burden. Reduced effective blood volume with consequent reduced renal blood flow, along with systemic inflammation in patients with decompensated cirrhosis, result in susceptibility to HRS. In this article, we will review updates over the last 5 years on the changing definition with diagnostic criteria and nomenclature of AKI and HRS, data on medical treatment with vasoconstrictors, and urinary biomarkers in diagnosis of etiology of AKI. We will also discuss the significance of liver transplantation evaluation once the diagnosis of HRS is established and the post-transplant immunosuppression management. We will also review one of the challenging issues that remains among transplant-eligible patients, that of allocation of simultaneous liver kidney transplant. Finally, we will review the new implemented policy from the Organ Procurement Transplant Network on simultaneous liver kidney allocation.
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Affiliation(s)
- Raseen Tariq
- Department of Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Ashwani K. Singal
- Division of Gastroenterology and Hepatology, University of South Dakota, Sanford School of Medicine, Sioux Falls, SD, USA
- Correspondence to: Ashwani K. Singal, Division of Gastroenterology and Hepatology, University of South Dakota, Sanford School of Medicine, Transplant Hepatologist and Chief Clinical Research Program, Avera Transplant and Research Institutes, Sioux Falls, SD 57105, USA. Tel: +1-605-322-8545, Fax: +1-605-322-8536, E-mail:
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Area Under Trough Concentrations of Tacrolimus as a Predictor of Progressive Renal Impairment After Liver Transplantation. Transplantation 2020; 103:2539-2548. [PMID: 31107827 DOI: 10.1097/tp.0000000000002760] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Tacrolimus minimization is usually restricted to patients with pretransplant renal impairment, and this strategy could result into worse renal outcomes after liver transplantation (LT). METHODS A consecutive cohort of 455 LT patients receiving tacrolimus-based immunosuppression was studied (2008-2013). Cumulative exposure to tacrolimus was calculated as the area under curve of trough concentrations (AUCtc). Patients were stratified as tacrolimus minimization, conventional, or high exposure, according to the thresholds based in the COMMIT consensus. Estimated glomerular filtration rates (eGFR) were assessed by the Modification of Diet in Renal Disease formula (MDRD-4) up to 5 years after LT. RESULTS Seventy patients (15.4%) had pretransplant eGFR < 60 mL/min, which was associated with increased mortality rates, particularly within the first 5 years post-LT (31.4% versus 17.5%; Breslow P = 0.010). After LT, there was an abrupt eGFR decline within the first 3 months (median 18.6 mL/min; P < 0.001), further decreasing up to 12 months (additional 3 mL/min), without any improvement thereafter. According to AUCtc, 33.7% of patients received tacrolimus minimization, 44.8% conventional exposure, and 21.5% high exposure. Conventional/high exposure to tacrolimus resulted in a more pronounced eGFR decline within the first 3 months when compared with minimization (23.3 mL/min versus 9.5 mL/min; P < 0.001). This gap was even higher in patients with initially preserved renal function. Tacrolimus AUCtc was an independent predictor of eGFR decline within the first 3 months after controlling for potential confounders. CONCLUSIONS AUCtc is a surrogate of cumulative exposure to tacrolimus and may be helpful for routine dose adjustments. Tacrolimus minimization should be universally attempted after LT to preserve renal function.
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Anesthesia for Kidney Transplantation. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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6
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Outcomes of Highly Sensitized Patients Undergoing Simultaneous Liver and Kidney Transplantation: A Single-Center Experience With Desensitization. Transplant Proc 2017; 49:1394-1401. [DOI: 10.1016/j.transproceed.2017.01.079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 01/24/2017] [Indexed: 01/24/2023]
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Halemani KR, Bhadrinath N. Combined liver and kidney transplantation: Our experience and review of literature. Indian J Anaesth 2017; 61:68-71. [PMID: 28216707 PMCID: PMC5296811 DOI: 10.4103/0019-5049.198392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Increased awareness of organ donation has increased the availability of deceased donors, and it has boosted the opportunities for treating patients with multiple organ dysfunction. Simultaneously replacing two organs gives advantages of single surgery, lower immunosuppression dose and better survival than when one organ alone is transplanted. We present reports of management of three cases of combined liver and kidney transplantation (CLKT) from deceased donors. Based on management of these cases we discuss the importance of CLKT and anaesthetic concerns during such complex procedures.
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Affiliation(s)
| | - N Bhadrinath
- Department of Anaesthesia, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
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Tariciotti L, Manzia TM, Sforza D, Anselmo A, Tisone G. Everolimus and Advagraf Ab Initio in Combined Liver and Kidney Transplant With Donor-Specific Antibodies: A Case Report. Transplant Proc 2016; 48:3109-3111. [PMID: 27932158 DOI: 10.1016/j.transproceed.2016.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/26/2016] [Indexed: 10/20/2022]
Abstract
Although donor-specific antibodies are regarded as a contraindication for kidney transplantation, the data available for combined liver and kidney transplantation (cLKTx) are scarce, and there is no established therapeutic approach for this category of transplant recipients. De novo use of everolimus and a reduced dose of calcineurin inhibitor reportedly provides excellent kidney function compared with a standard regimen containing a calcineurin inhibitor. This strategy, however, has been applied in only some recipient categories. Here we report a case of A highly sensitized male patient who underwent a cLKTx and received everolimus with low-dose tacrolimus (once-daily prolonged-release formulation) as ab initio immunosuppressive treatment. The pretransplant panel-reactive antibody estimate was 97%, and multiple anti-HLA antibodies were detected at the time of transplantation. Thus far, patient and allograft survival have reached 2 years, with the recipient remaining on a regimen of immunosuppression with everolimus and low-dose tacrolimus, with no episodes of rejection.
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Affiliation(s)
- L Tariciotti
- Liver and Kidney Transplant Centre, Policlinico "Tor Vergata", University of Rome "Tor Vergata", Rome, Italy.
| | - T M Manzia
- Liver and Kidney Transplant Centre, Policlinico "Tor Vergata", University of Rome "Tor Vergata", Rome, Italy
| | - D Sforza
- Liver and Kidney Transplant Centre, Policlinico "Tor Vergata", University of Rome "Tor Vergata", Rome, Italy
| | - A Anselmo
- Liver and Kidney Transplant Centre, Policlinico "Tor Vergata", University of Rome "Tor Vergata", Rome, Italy
| | - G Tisone
- Liver and Kidney Transplant Centre, Policlinico "Tor Vergata", University of Rome "Tor Vergata", Rome, Italy
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Thorat A, Jeng LB. Management of renal dysfunction in patients with liver cirrhosis: role of pretransplantation hemodialysis and outcomes after liver transplantation. Semin Vasc Surg 2016; 29:227-235. [DOI: 10.1053/j.semvascsurg.2017.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Abstract
It is important to accurately assess the glomerular filtration rate (GFR) of patients with liver disease to deliver care and allocate organs for transplantation in a way that improves outcomes. The most commonly used methods to estimate GFR in this population are based on creatinine, which is biased by these patients' low creatinine production and potentially by elevated serum bilirubin and decreased albumin levels. None of the creatinine-based estimated glomerular filtration rate (eGFR) equations have been specifically modified for a population with liver disease, and even measurement of a 24-hour creatinine clearance has limitations. In liver disease, all creatinine-based estimates of GFR overestimate gold standard-measured GFR, and the degree of overestimation is highest at lower measured GFR values and in more severe liver disease. Cystatin C-based eGFR has shown promise in general population studies by demonstrating less bias than creatinine-based eGFR and improved association with clinically important outcomes, but results in the liver disease population have been mixed, and further studies are necessary. Ultimately, specific eGFR equations for liver disease or novel methods for estimating GFR may be necessary. However, for now, the limitations of currently available methods need to be appreciated to understand kidney function in liver disease.
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Affiliation(s)
- Tomasz Beben
- University of California, San Diego, California Veterans Affairs San Diego Healthcare System, San Diego, CA
| | - Dena E Rifkin
- University of California, San Diego, California Veterans Affairs San Diego Healthcare System, San Diego, CA.
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12
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Beben T, Rifkin DE. GFR Estimating Equations and Liver Disease. Adv Chronic Kidney Dis 2015; 22:337-42. [PMID: 26311594 DOI: 10.1053/j.ackd.2015.05.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 03/05/2015] [Accepted: 05/11/2015] [Indexed: 12/20/2022]
Abstract
It is important to accurately assess the glomerular filtration rate (GFR) of patients with liver disease to deliver care and allocate organs for transplantation in a way that improves outcomes. The most commonly used methods to estimate GFR in this population are based on creatinine, which is biased by these patients' low creatinine production and potentially by elevated serum bilirubin and decreased albumin levels. None of the creatinine-based estimated glomerular filtration rate (eGFR) equations have been specifically modified for a population with liver disease, and even measurement of a 24-hour creatinine clearance has limitations. In liver disease, all creatinine-based estimates of GFR overestimate gold standard-measured GFR, and the degree of overestimation is highest at lower measured GFR values and in more severe liver disease. Cystatin C-based eGFR has shown promise in general population studies by demonstrating less bias than creatinine-based eGFR and improved association with clinically important outcomes, but results in the liver disease population have been mixed, and further studies are necessary. Ultimately, specific eGFR equations for liver disease or novel methods for estimating GFR may be necessary. However, for now, the limitations of currently available methods need to be appreciated to understand kidney function in liver disease.
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Veras FJDO, Coelho GR, Feitosa-Neto BA, Cerqueira JBG, Garcia RCFG, Garcia JHP. Combined liver-kidney transplantation: experience at a Brazilian university hospital. ACTA ACUST UNITED AC 2014; 27:53-5. [PMID: 24676300 PMCID: PMC4675492 DOI: 10.1590/s0102-67202014000100013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 12/12/2013] [Indexed: 05/28/2023]
Abstract
BACKGROUND Combined liver-kidney transplant is a routine procedure in many transplant centers. The increase in its number coincided with the introduction in 2002 of the MELD (Model for End-stage Liver Disease) score for allocation of livers, prioritizing patients with renal dysfunction. Aim : To analyze the experience with combined liver-kidney transplantation in a liver transplant center in Brazil. METHOD A retrospective review was conducted. All transplants were performed using grafts from deceased donors. RESULTS Sixteen combined liver-kidney transplantations were performed in the same period, which corresponds to 2.7% and 2.5% of the kidney and liver transplants, respectively. Fourteen patients were male (87.5 %) and two were female (12.5%). The average patients and donors age was 57.3 ± 9.1 and 32.7 ± 13.1, respectively. The MELD score mean was 23.6 ± 3.67. The main cause of liver dysfunction were chronic hepatitis C virus (n=9). As for renal dysfunction, diabetic nephropathy (n=4) was the most frequent. There were six deaths, two of them by severe dysfunction of the liver graft and four by infectious causes. The 1, 3 and 5 years survival rate in patients undergoing liver-kidney transplantations was 68.8%, 57.3% and 57.3%, respectively. CONCLUSION The survival rates achieved in this series are considered satisfactory and show that this procedure has an acceptable morbidity and survival.
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Jawan B, Wang CH, Chen CL, Huang CJ, Cheng KW, Wu SC, Shih TH, Yang SC. Review of anesthesia in liver transplantation. ACTA ACUST UNITED AC 2014; 52:185-96. [PMID: 25477262 DOI: 10.1016/j.aat.2014.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 09/26/2014] [Indexed: 01/10/2023]
Abstract
Liver transplantation (LT) is a well-accepted treatment modality of many end-stage liver diseases. The main issue in LT is the shortage of deceased donors to accommodate the needs of patients waiting for such transplants. Live donors have tremendously increased the pool of available liver grafts, especially in countries where deceased donors are not common. The main ethical concern of this procedure is the safety of healthy donors, who undergo a major abdominal surgery not for their own health, but to help cure others. The first part of the review concentrates on live donor selection, preanesthetic evaluation, and intraoperative anesthetic care for living liver donors. The second part reviews patient evaluation, intraoperative anesthesia monitoring, and fluid management of the recipient. This review provides up-to-date information to help improve the quality of anesthesia, and contribute to the success of LT and increase the long-term survival of the recipients.
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Affiliation(s)
- Bruno Jawan
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Chih-Hsien Wang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chao-Long Chen
- Liver Transplant Program, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Jung Huang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kwok-Wai Cheng
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tsung-Hsiao Shih
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Sheng-Chun Yang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Kuramitsu K, Fukumoto T, Iwasaki T, Tominaga M, Matsumoto I, Ajiki T, Ku Y. Long-term Complications After Liver Transplantation. Transplant Proc 2014; 46:797-803. [DOI: 10.1016/j.transproceed.2013.11.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 11/05/2013] [Indexed: 12/11/2022]
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Hibi T, Nishida S, Sageshima J, Levi DM, Ruiz P, Roth D, Martin P, Okabayashi K, Burke GW, Ciancio G, Tzakis AG. Excessive immunosuppression as a potential cause of poor survival in simultaneous liver/kidney transplantation for hepatitis C. Transpl Int 2014; 27:606-16. [PMID: 24606223 DOI: 10.1111/tri.12303] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 08/26/2013] [Accepted: 03/03/2014] [Indexed: 02/06/2023]
Abstract
Appropriate recipient selection of simultaneous liver/kidney transplantation (SLKT) remains controversial. In particular, data on liver graft survival in hepatitis C virus-infected (HCV+) SLKT recipients are lacking. We conducted a single-center, retrospective study of HCV+ SLKT recipients (N = 25) in comparison with HCV- SLKT (N = 26) and HCV+ liver transplantation alone (LTA, N = 296). Despite backgrounds of HCV+ and HCV- SLKT being similar, HCV+ SLKT demonstrated significantly impaired 5-year liver graft survival of 35% (HCV- SLKT, 79%, P = 0.004). Compared with HCV+ LTA, induction immunosuppression was more frequently used in HCV+ SLKT. Five-year liver graft survival rate for HCV+ SLKT was significantly lower than that for LTA (35% vs. 74%, respectively, P < 0.001). Adjusted hazard ratio of liver graft loss in HCV+ SLKT was 4.9 (95% confidence interval 2.0-12.1, P = 0.001). HCV+ SLKT recipients were more likely to succumb to recurrent HCV and sepsis compared with LTA (32% vs. 8.8%, P < 0.001 and 24% vs. 8.8%, P = 0.030, respectively). Ten HCV+ SLKT recipients underwent anti-HCV therapy for recurrent HCV; only 1 achieved sustained virological response. HCV+ SLKT is associated with significantly decreased long-term prognosis compared with HCV- SLKT and HCV+ LTA.
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Affiliation(s)
- Taizo Hibi
- Miami Transplant Institute, University of Miami Leonard M. Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA; DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA; Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Sharma S, Pande G, Saraswat VA, Saxena R. Simultaneous liver kidney transplant. INDIAN JOURNAL OF TRANSPLANTATION 2014. [DOI: 10.1016/j.ijt.2014.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Outcomes of simultaneous liver and kidney transplantation in relation to a high level of preformed donor-specific antibodies. Transplantation 2014; 96:914-8. [PMID: 23903012 DOI: 10.1097/tp.0b013e3182a192f5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The protective effect of the liver allograft when simultaneously transplanted with a kidney in the setting of allosensitization is unclear. METHODS We analyzed the significance of sensitization, defined based on positive cytotoxicity crossmatches, positive flow cytometry crossmatches, and/or the presence of high levels of donor-specific antibodies, on the outcomes of simultaneous liver and kidney (SLK) transplantation. We reviewed 56 SLK performed at our center through December 31, 2011 and identified 13 patients who met high sensitization criteria. RESULTS Median patient survival was not significantly different: 86 months (95% confidence interval [CI], 47-135) for nonsensitized patients versus 151 months (95% CI, 4 to ∞) for sensitized patients (P=0.5). The 5-year survival was 67% (95% CI, 0.5-0.8) in the nonsensitized group and 64% (95% CI, 0.3-0.9) in the sensitized group. There were six renal allograft failures in the nonsensitized group but none in the sensitized group. The adjusted hazard ratios associated with the risk of death or the combined risk of death or renal allograft failure were 0.7 (95% CI, 0.1-3.8) and 0.4 (95% CI, 0.1-2.2) for sensitized versus nonsensitized patients. There were significantly more renal allograft rejections in the sensitized group (5 vs. 1; P=0.002) in the first year after transplantation, only one showing C4d positivity. Creatinine levels at 1 year after transplantation were similar: 1.5 mg/dL in the nonsensitized group versus 1.36 mg/dL in the sensitized group (P=0.6). CONCLUSION Sensitization does not appear to have a significant negative impact on the survival of SLK patients.
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Bahirwani R, Forde KA, Mu Y, Lin F, Reese P, Goldberg D, Abt P, Reddy KR, Levine M. End-stage renal disease after liver transplantation in patients with pre-transplant chronic kidney disease. Clin Transplant 2014; 28:205-10. [PMID: 24382253 DOI: 10.1111/ctr.12298] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2013] [Indexed: 11/29/2022]
Abstract
UNLABELLED Renal dysfunction prior to liver transplantation has a marked impact on post-transplant kidney outcomes. AIM The aim of this study was to assess post-transplant renal function in patients with chronic kidney disease (CKD) receiving orthotopic liver transplantation (OLT) alone. METHODS Retrospective review of 40 OLT recipients with pre-transplant CKD (serum creatinine ≥2 mg/dL for at least three months) at the University of Pennsylvania from February 2002 to July 2010. Primary outcome was estimated glomerular filtration rate (eGFR) up to three years post-transplant. Secondary outcomes included incidence of stage 4 CKD (eGFR < 30 mL/min), need for renal replacement therapy (RRT), meeting criteria for kidney transplant listing (eGFR ≤ 20 mL/min), and mortality. RESULTS Median patient age was 56.5 yr and 48% patients had pre-transplant diabetes. Median serum creatinine at transplant was 2.7 mg/dL (eGFR = 24 mL/min). Median eGFR at one, two, and three yr post-transplant was 35, 34, and 37 mL/min, respectively. Twelve patients (30%) required RRT at a median of 1.21 yr post-transplant and 16 (40%) achieved an eGFR ≤ 20 mL/min at 1.09 yr post-transplant. Mortality was 35% at a median of 1.60 years post-transplant. CONCLUSIONS OLT recipients with pre-transplant CKD have a substantial burden of post-transplant renal dysfunction and high short-term mortality, questioning the rationale for OLT alone in this population.
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Affiliation(s)
- Ranjeeta Bahirwani
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Abstract
Patients undergoing abdominal organ transplantation have extensive comorbidities that can affect many organ systems including the cardiovascular system. Intraoperative anesthesia care can be very challenging and requires thorough understanding of the disease specific physiology as well as knowledge of the comorbidities and the surgical procedure. There is no approach to intraoperative anesthesia care that will work equally well for every center but standardization of protocols for each transplant center will improve patient care and safety and ultimately contributes to superior outcomes. In this article we provide background and suggestions that will help with the development of standardized protocols for intraoperative management.
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Affiliation(s)
- Michael D Spiro
- Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, 513 Parnassus Avenue, Room S-436, Box 0427, San Francisco, CA 94143, USA
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Low estimated glomerular filtration rate and chronic kidney failure following liver transplant: a retrospective cohort study. Int J Artif Organs 2013; 36:498-505. [PMID: 23897230 DOI: 10.5301/ijao.5000201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2012] [Indexed: 01/22/2023]
Abstract
BACKGROUND Patients undergoing orthotropic liver transplant (LTx) often present with chronic kidney disease (CKD). Identification of patients who will progress to end-stage renal disease (ESRD) might allow not only the implementation of kidney protective measures but also simultaneous kidney transplant. STUDY DESIGN Retrospective cohort study in adults who underwent LTx at a single center. ESRD, death, and composite of ESRD or death were studied outcomes. RESULTS 331 patients, who underwent LTx, were followed up for 2.6 ± 1.4 years; 31 (10%) developed ESRD, 6 (2%) underwent kidney transplant after LTx and 25 (8%) remained on chronic hemodialysis. Patients with preoperative eGFR lesser than 60 ml/min per 1.73 m2 had a 4-fold increased risk of developing ESRD after adjustment for sex, diabetes mellitus, APACHE II score, use of nephrotoxic drugs, and severe liver graft failure (HR = 3.95, 95% CI 1.73, 9.01; p = 0.001). Other independent risk factors for ESRD were preoperative diabetes mellitus and post-operative severe liver graft dysfunction. CONCLUSION These findings emphasize low eGFR prior to LTx as a predictor for ESRD or death. The consideration for kidney after liver transplant as a treatment modality should be taken into account for those who develop chronic kidney failure after LTx.
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Experience of Combined Liver-Kidney Transplantation for Acute-on-Chronic Liver Failure Patients With Renal Dysfunction. Transplant Proc 2013; 45:2307-13. [DOI: 10.1016/j.transproceed.2013.02.127] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 01/06/2013] [Accepted: 02/16/2013] [Indexed: 12/25/2022]
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Levitsky J, Baker T, Ahya SN, Levin ML, Friedewald J, Gallon L, Ho B, Skaro A, Krupp J, Wang E, Spies SM, Salomon DR, Abecassis MM. Outcomes and native renal recovery following simultaneous liver-kidney transplantation. Am J Transplant 2012; 12:2949-57. [PMID: 22759344 DOI: 10.1111/j.1600-6143.2012.04182.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
With the increase in patients having impaired renal function at liver transplant due to MELD, accurate predictors of posttransplant native renal recovery are needed to select candidates for simultaneous liver-kidney transplantation (SLK). Current UNOS guidelines rely on specific clinical criteria for SLK allocation. To examine these guidelines and other variables predicting nonrecovery, we analyzed 155 SLK recipients, focusing on a subset (n = 78) that had post-SLK native GFR (nGFR) determined by radionuclide renal scans. The 77 patients not having renal scans received a higher number of extended criteria donor organs and had worse posttransplant survival. Of the 78 renal scan patients, 31 met and 47 did not meet pre-SLK UNOS criteria. The UNOS criteria were more predictive than our institutional criteria for all nGFR recovery thresholds (20-40 mL/min), although at the most conservative cut-off (nGFR ≤ 20) it had low sensitivity (55.3%), specificity (75%), PPV (67.6%) and NPV (63.8%) for predicting post-SLK nonrecovery. On multivariate analysis, the only predictor of native renal nonrecovery (nGFR ≤ 20) was abnormal pre-SLK renal imaging (OR 3.85, CI 1.22-12.5). Our data support the need to refine SLK selection utilizing more definitive biomarkers and predictors of native renal recovery than current clinical criteria.
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Affiliation(s)
- J Levitsky
- Comprehensive Transplant Center, Northwestern University, Chicago, IL, USA.
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24
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Stages of Early Acute Renal Dysfunction in Liver Transplantation: The Influence of Graft Function. Transplant Proc 2012; 44:1953-5. [DOI: 10.1016/j.transproceed.2012.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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25
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Lim KBL, Schiano TD. Long-term outcome after liver transplantation. ACTA ACUST UNITED AC 2012; 79:169-89. [PMID: 22499489 DOI: 10.1002/msj.21302] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Liver transplantation is a life-saving therapy for patients with end-stage liver disease, acute liver failure, and liver tumors. Over the past 4 decades, improvements in surgical techniques, peritransplant intensive care, and immunosuppressive regimens have resulted in significant improvements in short-term survival. Focus has now shifted to addressing long-term complications and improving quality of life in liver recipients. These include adverse effects of immunosuppression; recurrence of the primary liver disease; and management of diabetes, hypertension, dyslipidemia, obesity, metabolic syndrome, cardiovascular disease, renal dysfunction, osteoporosis, and de novo malignancy. Issues such as posttransplant depression, employment, sexual function, fertility, and pregnancy must not be overlooked, as they have a direct impact on the liver recipient's quality of life. This review summarizes the latest data in long-term outcome after liver transplantation.
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Martin EF, Huang J, Xiang Q, Klein JP, Bajaj J, Saeian K. Recipient survival and graft survival are not diminished by simultaneous liver-kidney transplantation: an analysis of the united network for organ sharing database. Liver Transpl 2012; 18:914-29. [PMID: 22467623 PMCID: PMC3405201 DOI: 10.1002/lt.23440] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Recipients of solitary liver and kidney transplants are living longer, and this increases their risk of long-term complications such as recurrent hepatitis C virus (HCV) and drug-induced nephrotoxicity. These complications may require retransplantation. Since the adoption of the Model for End-Stage Liver Disease, the number of simultaneous liver-kidney transplantation (SLK) procedures has increased. However, there are no standardized criteria for organ allocation to SLK candidates. The aims of this study were to retrospectively compare recipient and graft survival with liver transplantation alone (LTA), SLK, kidney after liver transplantation (KALT), and liver after kidney transplantation (LAKT) and to identify independent risk factors affecting recipient and graft survival. The United Network for Organ Sharing/Organ Procurement and Transplantation Network database (1988-2007) was queried for adult LTA (66,026), SLK (2327), KALT (1738), and LAKT procedures (242). After adjustments for potential confounding demographic and clinical variables, there was no difference in recipient mortality rates with LTA and SLK (P = 0.02). However, there was a 15% decreased risk of graft loss with SLK versus LTA (hazard ratio = 0.85, P < 0.001). The recipient and graft survival rates with SLK were higher than the rates with both KALT (P <0.001 and P <0.001) and LAKT (P = 0.003 and P < 0.001). The following were all identified as independent negative predictors of recipient mortality and graft loss: recipient age ≥ 65 years, male sex, black race, HCV/diabetes mellitus status, donor age ≥ 60 years, serum creatinine level ≥2.0 mg/dL, cold ischemia time > 12 hours, and warm ischemia time > 60 minutes. Although the recent increase in the number of SLK procedures performed each year has effectively decreased the number of potential donor kidneys available to patients with end-stage renal disease (ESRD) awaiting kidney transplantation, SLK in patients with end-stage liver disease and ESRD is justified because of the lower risk of graft loss with SLK versus LTA as well as the superior recipient and graft survival with SLK versus serial liver-kidney transplantation.
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Affiliation(s)
- Eric F Martin
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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Baker TB, Abecassis M, Levitsky J. To kidney or not to kidney, when … is the question. Liver Transpl 2012; 18:875-7. [PMID: 22829417 DOI: 10.1002/lt.23462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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28
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Sakamoto S, Kasahara M, Fukuda A, Tanaka H, Kakiuchi T, Karaki C, Kanazawa H, Kamei K, Ito S, Nakazawa A. Pediatric liver-kidney transplantation for hepatorenal fibrocystic disease from a living donor. Pediatr Transplant 2012; 16:99-102. [PMID: 22151180 DOI: 10.1111/j.1399-3046.2011.01609.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The indications for and the timing of LT and/or KT for the patients with HRFCD are based on the severity of liver and kidney involvement. Most organs come from living donors, because the number of deceased donors is extremely low in Japan. Therefore, patients with HRFCD may need two organs from living donors. Four patients with HRFCD underwent living donor LT and KT from a single donor. The type of transplantation included combined LKT in one case, sequential LKT in two cases, and sequential KLT in one case. Although the case of combined LKT died because of sepsis, the other cases were doing well. Sequential LKT was successfully performed at the proper timing for each transplant; however, both of the donors suffered from a gastroduodenal ulcer after liver donation because of the psychological burden related to the relatively short period between two donations. In conclusion, living donation for LKT with cautious surgical procedures is not harmful for donors and recipients. However, changes in the allocation system established for deceased donors for HRFCD should be considered to avoid the need for two organ donations from the same living donor.
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Affiliation(s)
- Seisuke Sakamoto
- Division of Transplant Surgery, National Center for Child Health and Development, Tokyo, Japan.
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29
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Gleisner AL, Jung H, Lentine KL, Tuttle-Newhall J. Renal Dysfunction in Liver Transplant Candidates: Evaluation, Classification and Management in Contemporary Practice. Nephrol Ther 2012; Suppl 4. [PMID: 32874772 DOI: 10.4172/2161-0959.s4-006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Renal dysfunction is a common comorbidity in patients with liver failure and is a well-established predictor of both morbidity and mortality among patients awaiting liver transplantation. The etiology of renal failure in patients with cirrhosis can be functional, structural, or represent a combination of potentially reversible physiologic changes and permanent histologic damage. Diagnostic criteria for acute and chronic kidney disease have been established, but cirrhosis poses challenges for accurate assessment of renal function with conventional clinical methods such as serum creatinine and creatinine-based estimating equations. Renal biopsies can have an important role for defining permanent structural damage as part of the pre-transplant evaluation of patients with liver disease; however, coagulopathy, portal hypertension and ascites increase the risk of biopsy-associated complications in cirrhotic patients. While renal dysfunction due to hepatorenal physiology is potentially reversible after liver transplantation, simultaneous kidney liver transplantation and kidney after liver transplant can also improve outcomes in a subset of patients with irreversible renal injury.
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Affiliation(s)
- Ana L Gleisner
- Division of Abdominal Organ Transplantation, Department of Surgery, Saint Louis University Medical Center, St. Louis, MO
| | - HeeSoo Jung
- Division of Abdominal Organ Transplantation, Department of Surgery, Saint Louis University Medical Center, St. Louis, MO
| | - Krista L Lentine
- Division of Abdominal Organ Transplantation, Department of Surgery, Saint Louis University Medical Center, St. Louis, MO
| | - Janet Tuttle-Newhall
- Division of Abdominal Organ Transplantation, Department of Surgery, Saint Louis University Medical Center, St. Louis, MO
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Abstract
Hepatorenal syndrome (HRS) is a functional form of acute kidney injury (AKI) associated with advanced liver cirrhosis or fulminant hepatic failure. Various new concepts have emerged since the initial diagnostic criteria and definition of HRS was initially published. These include better understanding of the pathophysiological mechanisms involved in HRS, identification of bacterial infection (especially spontaneous bacterial peritonitis) as the most important HRS-precipitating event, recognition that insufficient cardiac output plays a role in the occurrence of HRS, and evidence that renal failure reverses with pharmacotherapy. Patients with HRS are often critically ill and, by definition, have multiorgan failure. The purpose of this review is to provide an update on novel advances in HRS, with emphasis on the different aspects of management of these patients in the intensive care unit.
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Affiliation(s)
- Hani M Wadei
- Department of Transplantation, College of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA.
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31
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Abstract
Simultaneous liver and kidney transplantation is a life saving procedure for patients with combined liver and kidney failure; however, it remains controversial because of the need to balance individual patient need versus resource allocation. As waiting lists for transplantation become longer and patients become increasingly ill, there will be greater numbers of patients referred for liver and kidney transplantation. Acute kidney injury even requiring dialysis may potentially be reversible making combined transplant decisions difficult. Similarly, selected compensated cirrhotic patients with renal failure may be managed with renal transplant alone. Shared multicenter experience or clinical trials or both will be required to refine our ability to optimally manage these patients with combined liver and kidney dysfunction.
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Iglesias JI, DePalma JA, Levine JS. Risk factors for acute kidney injury following orthotopic liver transplantation: the impact of changes in renal function while patients await transplantation. BMC Nephrol 2010; 11:30. [PMID: 21059264 PMCID: PMC2991287 DOI: 10.1186/1471-2369-11-30] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 11/08/2010] [Indexed: 12/18/2022] Open
Abstract
Background Acute kidney injury (AKI) occurs commonly in the setting of orthotopic liver transplantation (OLT). To date, the correlation between AKI post-OLT and pre-operative changes in renal function has not been rigorously examined. Methods To determine the impact of pre-OLT changes in renal function on AKI post-OLT, as well as to identify risk factors for AKI, we analyzed the prospectively maintained NIDDK Liver Transplantation Database, which includes patients who received their first OLT between April 15, 1990, and June 30, 1994. We used the AKI Network definition of AKI. Results Surprisingly, univariate analysis revealed that worsening renal function while awaiting OLT was protective to the development of AKI post-OLT. Independent predictors of AKI were increased body mass index, increased Childs-Pugh-Turcott score, decreased urine output during cross-clamp, improved renal function while awaiting OLT, increased post-operative stroke volume, non-Caucasian race, and post-operative use of tacrolimus. Conclusions The correlation between improving renal function pre-OLT and AKI post-OLT may represent true protection (via ischemic pre-conditioning) or, alternatively, a masking of milder forms of AKI (via improved renal perfusion through correction of the cirrhotic milieu). These results highlight the complex interaction between liver and kidney disease, and suggest that not only the etiology but also the course of pre-OLT renal dysfunction may be a critical determinant of renal function post-OLT.
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Affiliation(s)
- Jose I Iglesias
- Department of Medicine subsection of Nephrology, UMDNJ School of Osteopathic Medicine, Stratford, NJ 08084, USA.
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33
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Chava SP, Singh B, Stangou A, Battula N, Bowles M, O'Grady J, Rela M, Heaton ND. Simultaneous combined liver and kidney transplantation: a single center experience. Clin Transplant 2010; 24:E62-8. [PMID: 20618811 DOI: 10.1111/j.1399-0012.2010.01168.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Renal dysfunction is common in patients awaiting liver transplantation (LT) and affects outcome following LT. Combined liver and kidney transplantation (CLKT) has been proposed as effective treatment for patients with chronic diseases of both organs, some with hepatorenal syndrome and for liver-based metabolic diseases affecting kidney. This study is undertaken to analyze results of CLKT at a single center. Of 2690 LTs performed between 1992 and 2007, there were 39 CLKTs; most common indications were metabolic, cirrhosis and polycystic disease. With follow-up of up to 170 months, 11 died (overall survival 71.8%); one-, five-, and 10-yr patient and liver graft survival is 77%, 73.7%, and 73.7%, respectively, and kidney graft survival is 77%, 70%, and 70%, respectively. Survival among metabolic group (78.6%) appeared to be better than non-metabolic group (68%); however, this difference was not significant (p = 0.39). Fifteen surviving patients (53.6%) have mild/moderate renal impairment (creatinine > or = 125 micromol/L). None has severe renal failure (serum creatinine > or = 250 micromol/L) or end-stage renal disease requiring hemodialysis. CLKT has good results in selected groups of patients. It provides protection to kidney allograft in liver-based metabolic diseases affecting kidney. The rate of acute rejection episodes of kidney is low. Significant proportion develops long-term mild/moderate renal dysfunction. Careful attention to immunosuppression to minimize nephrotoxicity may help.
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Affiliation(s)
- Srinivas P Chava
- Institute of Liver Studies, King's College Hospital, Denmark Hill, SE5 9RS London, UK
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34
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Risk Score Predicting Decline in Renal Function Postliver Transplant: Role in Patient Selection for Combined Liver Kidney Transplantation. Transplantation 2010; 89:1378-84. [DOI: 10.1097/tp.0b013e3181d9e195] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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35
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Chronic Kidney Disease–Epidemiology Formula and Model for End-Stage Liver Disease Score in the Assessment of Renal Function in Candidates for Liver Transplantation. Transplant Proc 2010; 42:1229-32. [DOI: 10.1016/j.transproceed.2010.03.129] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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36
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Mehrabi A, Fonouni H, Ayoub E, Rahbari NN, Müller SA, Morath C, Seckinger J, Sadeghi M, Golriz M, Esmaeilzadeh M, Hillebrand N, Weitz J, Zeier M, Büchler MW, Schmidt J, Schmied BM. A single center experience of combined liver kidney transplantation. Clin Transplant 2010; 23 Suppl 21:102-14. [PMID: 19930323 DOI: 10.1111/j.1399-0012.2009.01146.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
With advancements in the operative techniques, patient survival following liver transplantation (LTx) has increased substantially. This has led to the acceleration of pre-existing kidney disease because of immunosuppressive nephrotoxicity making additional kidney transplantation (KTx) inevitable. On the other hand, in a growing number of patients on the waiting list to receive liver, long waiting time has resulted in adverse effect of decompensated liver on the kidney function. During the last two decades, the transplant community has considered combined liver kidney transplantation (CLKTx) to overcome this problem. The aim of our study is to present an overview of our experience as well as a review of the literature in CLKTx and to discuss the controversy in this regard. All performed CLKTx (n = 22) at our institution as well as all available reported case series focusing on CLKTx are extracted. The references of the manuscripts were cross-checked to implement further articles into the review. The analyzed parameters include demographic data, indication for LTx and KTx, duration on the waiting list, Model for End-Stage Liver Disease (MELD) score, Child-Turcotte-Pugh (CTP) score, immunosuppressive regimen, post-transplant complications, graft and patient survival, and cause of death. From 1988 to 2009, a total of 22 CLKTx were performed at our institution. The median age of the patients at the time of CLKTx was 44.8 (range: 4.5-58.3 yr). The indications for LTx were liver cirrhosis, hyperoxaluria type 1, polycystic liver disease, primary or secondary sclerosing cholangitis, malignant hepatic epithelioid hemangioendothelioma, cystinosis, and congenital biliary fibrosis. The KTx indications were end-stage renal disease of various causes, hyperoxaluria type 1, polycystic kidney disease, and cystinosis. The mean follow-up duration for CLKTx patients were 4.6 +/- 3.5 yr (range: 0.5-12 yr). Overall, the most important encountered complications were sepsis (n = 8), liver failure leading to retransplantation (n = 4), liver rejection (n = 3), and kidney rejection (n = 1). The overall patient survival rate was 80%. Review of the literature showed that from 1984 to 2008, 3536 CLKTx cases were reported. The main indications for CLKTx were oxalosis of both organs, liver cirrhosis and chronic renal failure, polycystic liver and kidney disease, and liver cirrhosis along with hepatorenal syndrome (HRS). The most common encountered complications following CLKTx were infection, bleeding, biliary complications, retransplantation of the liver, acute hepatic artery thrombosis, and retransplantation of the kidney. From the available data regarding the need for post-operative dialysis (n = 673), a total of 175 recipients (26%) required hemodialysis. During the follow-up period, 154 episodes of liver rejection (4.3%) and 113 episodes of kidney rejection (3.2%) occurred. The cumulative 1, 2, 3, and 5 yr survival of both organs were 78.2%, 74.4%, 62.4%, and 60.9%, respectively. Additionally, the cumulative 1, 2, 3, and 5 yr patient survival were 84.9%, 52.8%, 45.4%, and 42.6%, respectively. The total number of reported deaths was 181 of 2808 cases (6.4%), from them the cause of death in 99 (55%) cases was sepsis. It can be concluded that there is still no definitive evidence of better graft and patient survival in CLKTx recipients when compared with LTx alone because of the complexity of the exact definition of irreversible kidney function in LTx candidates. Additionally, CLKTx is better to be performed earlier than isolated LTx and KTx leading to the avoidance of deterioration of clinical status, high rate of graft loss, and mortality. Shorter graft ischemia time and more effective immunosuppressive regimens can reduce the incidence of graft malfunctioning in CLKTx patients. Providing a model to reliably determine the need for CLKTx seems necessary. Such a model can be shaped based upon new and precise markers of renal function, and modification of MELD system.
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Affiliation(s)
- A Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
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Pirson Y. Extrarenal manifestations of autosomal dominant polycystic kidney disease. Adv Chronic Kidney Dis 2010; 17:173-80. [PMID: 20219620 DOI: 10.1053/j.ackd.2010.01.003] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 01/04/2010] [Accepted: 01/04/2010] [Indexed: 12/12/2022]
Abstract
Although asymptomatic in most patients, extrarenal manifestations of ADPKD may become more clinically relevant with the increasing life expectancy of affected patients. They mainly encompass cysts in other organs than the kidney (liver: 94%, seminal vesicle: 40%, pancreas: 9%, arachnoid membrane: 8%, and spinal meningeal, 2%) and connective tissue abnormalities (mitral valve prolapse: 25%, intracranial aneurysms: 8%, and abdominal hernia: 10%). Their recognition may spare the patient from other, useless investigations (eg, when an arachnoid cyst is incidentally found) or lead to the implementation of prophylactic or therapeutic measures (eg, screening, sometimes followed by the treatment of an asymptomatic intracranial aneurysm in at-risk patients, or, in the presence of a severe polycystic liver disease, avoidance from estrogens and treatment aimed to slow cyst growth).
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Baccaro ME, Pepin MN, Guevara M, Colmenero J, Torregrosa JV, Martin-Llahi M, Sola E, Esforzado N, Fuster J, Campistol JM, Arroyo V, Navasa M, Garcia-Valdecasas J, Gines P. Combined liver-kidney transplantation in patients with cirrhosis and chronic kidney disease. Nephrol Dial Transplant 2010; 25:2356-63. [DOI: 10.1093/ndt/gfq024] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Abstract
1. Chronic kidney disease is a common complication after liver transplantation and has a major impact on graft and patient survival. 2. Pretransplant renal dysfunction is the most important determinant of posttransplant chronic kidney disease; other factors include the presence of diabetes/hypertension, acute kidney injury pre-transplant and post-transplant, and the use of calcineurin inhibitor-based immunosuppression. 3. The most common cause of end-stage renal disease post-orthotopic liver transplantation is calcineurin inhibitor toxicity, and this emphasizes the need for calcineurin inhibitor minimization protocols post-transplant. 4. The presence of chronic kidney disease post-orthotopic liver transplantation not only is important with respect to the need for renal replacement therapy and kidney transplantation but also increases cardiovascular risk dramatically. 5. The Model for End-Stage Liver Disease score is partly driven by creatinine, and it is not uncommon to have an elevated creatinine level in those who have a high Model for End-Stage Liver Disease score and are close to having an organ allocated. Thus, evaluating patients with advanced liver disease and pretransplant acute kidney injury is challenging. It is important to identify pre-liver transplant patients at high risk for early evolution of chronic kidney disease post-transplant in order to appropriately select patients for combined liver/kidney transplantation.
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40
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Charlton MR, Wall WJ, Ojo AO, Ginès P, Textor S, Shihab FS, Marotta P, Cantarovich M, Eason JD, Wiesner RH, Ramsay MA, Garcia-Valdecasas JC, Neuberger JM, Feng S, Davis CL, Gonwa TA. Report of the first international liver transplantation society expert panel consensus conference on renal insufficiency in liver transplantation. Liver Transpl 2009; 15:S1-34. [PMID: 19877213 DOI: 10.1002/lt.21877] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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41
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Affiliation(s)
- Pere Ginès
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, and Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Catalonia, Spain
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42
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Chava SP, Singh B, Pal S, Dhawan A, Heaton ND. Indications for combined liver and kidney transplantation in children. Pediatr Transplant 2009; 13:661-9. [PMID: 19566856 DOI: 10.1111/j.1399-3046.2008.01046.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A significant number of patients awaiting liver transplantation have associated renal failure and renal dysfunction is associated with increased morbidity and mortality after LT. There has been a recent increase in the number of CLKT in adults. The common indications for CLKT in children are different from those of adults and include metabolic diseases affecting the kidney with or without liver dysfunction and congenital developmental abnormalities affecting both organs. The results are generally encouraging among these groups of patients. Early evaluation and listing of patients before they become severely ill or have major systemic manifestations of their metabolic problem are important.
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Affiliation(s)
- Srinivas P Chava
- Institute of Liver Studies, Kings College London School of Medicine, King's College Hospital, London, UK
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43
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Wadei HM, Davis CL. Renal replacement therapy in the liver transplant candidate. Adv Chronic Kidney Dis 2009; 16:250-5. [PMID: 19576555 DOI: 10.1053/j.ackd.2009.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Since the implementation of the model of end-stage liver disease score to prioritize patients for orthotopic liver transplantation (OLT), the number of liver transplant candidates with renal failure and on renal replacement therapy (RRT) has dramatically increased. This review is intended to discuss the indications and implications of RRT initiation, the different RRT modalities, and special problems encountered with RRT in OLT candidates.
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44
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Bloom RD, Bleicher M. Simultaneous liver-kidney transplantation in the MELD era. Adv Chronic Kidney Dis 2009; 16:268-77. [PMID: 19576557 DOI: 10.1053/j.ackd.2009.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Impaired kidney function is common in liver transplant candidates and portends heightened risk for both postoperative chronic kidney disease and mortality. The weighting of serum creatinine in the Model of End-stage Liver Disease classification for liver allocation has been accompanied by a proliferation of simultaneous liver-kidney transplants in recent years. In the absence of standardized criteria for allocating kidneys in this setting, there is a wide variation in combined organ transplants across transplant centers. This review discusses the issues surrounding simultaneous liver-kidney transplantation and proposes a strategy for selecting patients to receive both organs.
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45
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Abstract
Model for End-Stage Liver Disease (MELD) allocation has improved the process for ranking patients on the liver transplant list. One unintended consequence has been an increase in the number of simultaneous liver-kidney (SLK) transplants. Some have argued that the system unfairly advantages patients with kidney disease and that some kidneys are being prematurely placed in SLK transplantation. This review summarizes the MELD score, assessment of kidney function in cirrhosis, the impact of kidney function in liver disease, and changes in kidney function status in liver transplant recipients in the MELD era. Finally, recommendations regarding who should receive SLK transplants are reviewed.
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Chava SP, Singh B, Zaman MB, Rela M, Heaton ND. Current indications for combined liver and kidney transplantation in adults. Transplant Rev (Orlando) 2009; 23:111-9. [PMID: 19298942 DOI: 10.1016/j.trre.2009.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
UNLABELLED A significant number of patients awaiting liver transplantation have associated renal failure. Combined Liver and Kidney Transplantation (CLKT) is increasingly offered especially since the introduction of Model for End-Stage Liver Disease (MELD). Decision to perform CLKT is straightforward when both organs suffer end-stage failure. However, the indications for CLKT are not well defined and there is controversy concerning some. We reviewed available data on PUBMED, United Network for Organ Sharing (UNOS), Organ Procurement Transplantation Network (OPTN), European Society for Organ Transplantation (ESOT) and discuss all current indications for CLKT. CONCLUSION Overall long-term outcome following CLKT is acceptable. There is an urgent need to further refine our ability to identify the cases with reversible renal injury in the setting of end-stage liver disease to avoid unnecessary CLKT. Liver protects the kidney from disease recurrence and allograft loss in metabolic diseases. However, the use of liver allograft for immunological protection of kidneys in highly sensitised patients with positive cross-match and previously failed renal transplants is still experimental.
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Affiliation(s)
- Srinivas P Chava
- King's College London School of Medicine at King's College Hospital, Institute of Liver Studies, Denmark Hill, Camberwell, SE5 9RS London, UK
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Lalazar G, Adar T, Ilan Y. Point-of-care continuous 13C-methacetin breath test improves decision making in acute liver disease: Results of a pilot clinical trial. World J Gastroenterol 2009; 15:966-72. [PMID: 19248196 PMCID: PMC2653395 DOI: 10.3748/wjg.15.966] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the role of the 13C-methacetin breath test (MBT) in patients with acute liver disease.
METHODS: Fifteen patients with severe acute liver disease from diverse etiologies were followed-up with 13C-MBT during the acute phase of their illnesses (range 3-116 d after treatment). Patients fasted for 8 h and ingested 75 mg of methacetin prior to the MBT. We compared results from standard clinical assessment, serum liver enzymes, synthetic function, and breath test scores.
RESULTS: Thirteen patients recovered and two patients died. In patients that recovered, MBT parameters improved in parallel with improvements in lab results. Evidence of consistent improvement began on day 3 for MBT parameters and between days 7 and 9 for blood tests. Later convergence to normality occurred at an average of 9 d for MBT parameters and from 13 to 28 d for blood tests. In both patients that died, MBT parameters remained low despite fluctuating laboratory values.
CONCLUSION: The 13C-MBT provides a rapid, non-invasive assessment of liver function in acute severe liver disease of diverse etiologies. The results of this pilot clinical trial suggest that the MBT may offer greater sensitivity than standard clinical tests for managing patients with severe acute liver disease.
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Analysis of Kidney Function and Biopsy Results in Liver Failure Patients With Renal Dysfunction: A New Look to Combined Liver Kidney Allocation in the Post-MELD Era. Transplantation 2008; 86:1548-53. [DOI: 10.1097/tp.0b013e31818b22cc] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Wadei HM, Geiger XJ, Cortese C, Mai ML, Kramer DJ, Rosser BG, Keaveny AP, Willingham DL, Ahsan N, Gonwa TA. Kidney allocation to liver transplant candidates with renal failure of undetermined etiology: role of percutaneous renal biopsy. Am J Transplant 2008; 8:2618-26. [PMID: 19032225 DOI: 10.1111/j.1600-6143.2008.02426.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The feasibility, value and risk of percutaneous renal biopsy (PRB) in liver transplant candidates with renal failure are unknown. PRB was performed on 44 liver transplant candidates with renal failure of undetermined etiology and glomerular filtration rate (GFR) <40 mL/min/1.73 m(2) (n = 37) or on renal replacement therapy (RRT) (n = 7). Patients with >or=30% interstitial fibrosis (IF), >or=40% global glomerulosclerosis (gGS) and/or diffuse glomerulonephritis were approved for simultaneous-liver-kidney (SLK) transplantation. Prebiopsy GFR, urinary sodium indices, dependency on RRT and kidney size were comparable between 27 liver-transplant-alone (LTA) and 17 SLK candidates and did not relate to the biopsy diagnosis. The interobserver agreement for the degree of IF or gGS was moderate-to-excellent. After a mean of 78 +/- 67 days, 16 and 8 patients received LTA and SLK transplants. All five LTA recipients on RRT recovered kidney function after transplantation and serum creatinine was comparable between LTA and SLK recipients at last follow-up. Biopsy complications developed in 13, of these, five required intervention. PRB is feasible in liver transplant candidates with renal failure and provides reproducible histological information that does not relate to the pretransplant clinical data. Randomized studies are needed to determine if PRB can direct kidney allocation in this challenging group of liver transplant candidates.
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Affiliation(s)
- H M Wadei
- Department of Transplantation, Mayo Clinic and Foundation, Jacksonville, FL, USA.
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Renal Graft Outcome in Simultaneous Kidney Transplantation Combined With Other Organs: Experience of a Single Center. Transplant Proc 2008; 40:3424-7. [DOI: 10.1016/j.transproceed.2008.06.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 06/04/2008] [Indexed: 11/21/2022]
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