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Prudhomme T, Mesnard B, Branchereau J, Roumiguié M, Maulat C, Muscari F, Kamar N, Soulié M, Gamé X, Sallusto F, Timsit MO, Drouin S. Simultaneous liver-kidney transplantation: future perspective. World J Urol 2024; 42:489. [PMID: 39162870 PMCID: PMC11335780 DOI: 10.1007/s00345-024-05174-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 07/11/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND The aims of this narrative review were (i) to describe the current indications of SLKT, (ii) to report evolution of SLKT activity, (iii) to report the outcomes of SLKT, (iv) to explain the immune-protective effect of liver transplant on kidney transplant, (v) to explain the interest of delay kidney transplantation, using hypothermic machine perfusion (HMP), (vi) to report kidney after liver transplantation (KALT) indications and (vii) to describe the value of the increase in the use of extended criteria donors (ECD) and particular controlled donation after circulatory death (cDCD) transplant, thanks to the development of new organ preservation strategies. METHOD Electronic databases were screened using the keywords "Simultaneous", "Combined", "kidney transplantation" and "liver transplantation". The methodological and clinical heterogeneity of the included studies meant that meta-analysis was inappropriate. RESULTS A total of 1,917 publications were identified in the literature search. Two reviewers screened all study abstracts independently and 1,107 of these were excluded. Thus, a total of 79 full text articles were assessed for eligibility. Of these, 21 were excluded. In total, 58 studies were included in this systematic review. CONCLUSIONS Simultaneous liver-kidney transplantation has made a significant contribution for patients with dual-organ disease. The optimization of indication and selection of SLKT patients will reduce futile transplantation. Moreover, increasing the use of transplants from extended criteria donors, in particular cDCD, should be encouraged, thanks to the development of new modalities of organ preservation.
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Affiliation(s)
- Thomas Prudhomme
- Department of Urology, Kidney Transplantation and Andrology, TSA 50032 Rangueil Hospital, Toulouse Cedex 9, 31059, France.
- Center for Research in Transplantation and Translational Immunology, Nantes Université, INSERM, UMR 1064, Nantes, 44000, France.
| | - Benoit Mesnard
- Center for Research in Transplantation and Translational Immunology, Nantes Université, INSERM, UMR 1064, Nantes, 44000, France
- Department of Urology, University Hospital of Nantes, Nantes, France
| | - Julien Branchereau
- Center for Research in Transplantation and Translational Immunology, Nantes Université, INSERM, UMR 1064, Nantes, 44000, France
- Department of Urology, University Hospital of Nantes, Nantes, France
| | - Mathieu Roumiguié
- Department of Urology, Kidney Transplantation and Andrology, TSA 50032 Rangueil Hospital, Toulouse Cedex 9, 31059, France
| | - Charlotte Maulat
- Department of Digestive Surgery, University Hospital of Rangueil, Toulouse, France
| | - Fabrice Muscari
- Department of Digestive Surgery, University Hospital of Rangueil, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, University Hospital of Rangueil, Toulouse, France
| | - Michel Soulié
- Department of Urology, Kidney Transplantation and Andrology, TSA 50032 Rangueil Hospital, Toulouse Cedex 9, 31059, France
| | - Xavier Gamé
- Department of Urology, Kidney Transplantation and Andrology, TSA 50032 Rangueil Hospital, Toulouse Cedex 9, 31059, France
| | - Federico Sallusto
- Department of Urology, Kidney Transplantation and Andrology, TSA 50032 Rangueil Hospital, Toulouse Cedex 9, 31059, France
| | - Marc Olivier Timsit
- Department of Urology, Hôpital Européen Georges Pompidou, APHP-Centre, Paris, France
| | - Sarah Drouin
- Service Médico-Chirurgical de Transplantation Rénale, APHP Sorbonne-Université, Hôpital Pitié-Salpêtrière, Paris, Île-de-France, France
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Macech M, Małyszko J, Nazarewski S, Kościelska M, Krawczyk P, Grąt M, Gałązka Z. Outcomes of Combined Liver-Kidney Transplantation - Single Center Experience. Transplant Proc 2024; 56:832-835. [PMID: 38719623 DOI: 10.1016/j.transproceed.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/29/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND There is continuous growth of combined liver-kidney transplantation (CLKTx) numbers with remarkable outcomes, especially among patient with liver cirrhosis and end-stage renal disease. The aim was to present a single center experience. METHODS Twenty patients (9 males) with a mean age of 48 (range: 20-62) years underwent CLKTx from 2005 to 2022. Indications were polycystic liver and kidney diseases (ADPKD) in 12 cases, cirrhosis due to hepatitis (4 patients), and 1 case of amyloidosis, alcoholic liver disease, nonalcoholic steatosis, and congenital hepatic fibrosis with concomitant glomerulonephritis. After hepatectomy, half of the patients had orthotopic liver transplantation with piggy-back technique, and the other had conventional technique. All but 1 recipient had biliary end-to-end anastomosis. 3 patients had preemptive kidney graft transplantation. 4 underwent simultaneous right-side nephrectomy due to volume of the right kidney. Kidney was transplanted from the separate incision after abdominal closure with typical anastomoses. Tacrolimus, mycophenolate mofetile, basiliximab, and steroids were applied for all recipients. RESULTS Mean follow-up was 57.7 ± 54 months. No primary non-function of the grafts occurred. Delayed kidney graft function (DGF) occurred in 8 patients. Three-month, 1-year, and 5-year cumulative survival rates were: 90%, 80%, and 72% respectively. None of the patients required retransplantation, and 1 recipient returned to hemodialysis 19 months after transplantation. Preemptive kidney transplantation and simultaneous right-side nephrectomy were not significant for DGF and recipient survival. No deaths within the first year occurred in piggy-back technique. CONCLUSIONS CLKTx is safe and effective in the treatment of both liver and kidney failure.
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Affiliation(s)
- Michał Macech
- Department of General, Vascular, Endocrine and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland.
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Sławomir Nazarewski
- Department of General, Vascular, Endocrine and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Małgorzata Kościelska
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Krawczyk
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Michał Grąt
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Zbigniew Gałązka
- Department of General, Vascular, Endocrine and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
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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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Bouari S, Polak WG, van de Wetering J, Metselaar HJ, IJzermans JNM, Minnee RC. Combined liver-kidney transplantation with delayed kidney implantation: A case report. Int J Surg Case Rep 2023; 106:108276. [PMID: 37150159 DOI: 10.1016/j.ijscr.2023.108276] [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: 04/04/2023] [Revised: 04/24/2023] [Accepted: 04/27/2023] [Indexed: 05/09/2023] Open
Abstract
INTRODUCTION In rare cases, patients require a combined liver-kidney transplant. However, the peri- and postoperative care of liver transplant recipients differs from kidney transplant recipients, which can lead to conflicts of interest. In the case of poor coagulation status and/or instable hemodynamics of the patient, liver transplantation, followed by delayed kidney transplantation can lead to better postoperative recovery. PRESENTATION OF CASE In our case report, we present a 48-year old man with Alagille syndrome and IgA nephropathy with bilirubin-associated acute kidney injury, causing him to develop both end-stage liver and kidney disease. He underwent a combined liver-kidney transplant as the first patient in the Netherlands, in which the donor kidney was transplanted one day after the liver transplantation. One-year post-transplant patient is in good clinical condition, with normal liver function and an eGFR of 57 ml/min. CONCLUSION Combined liver-kidney transplantation with delayed kidney implantation in a medical center with no previous experience with this technique is feasible and safe. This could be better for both the patient and the kidney graft.
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Affiliation(s)
- Sarah Bouari
- 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
| | - Jacqueline van de Wetering
- Department of Internal Medicine, Section of Nephrology and Transplantation, Erasmus MC University Transplant Institute, Rotterdam, the Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, 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
| | - Robert C Minnee
- Department of Surgery, Division of HPB & Transplant Surgery, Erasmus MC University Transplant Institute, Rotterdam, the Netherlands.
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Tariq N, Saharia A, Nwokedi U, Hobeika MJ, Mobley CM, Hsu D, Potter LM, Moore LW, Elaileh A, Sherman V, Ghobrial RM. Combined liver transplantation and sleeve gastrectomy: Report of a brief-interval staged approach. Liver Transpl 2023; 29:422-430. [PMID: 37160061 DOI: 10.1002/lt.26560] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 07/16/2022] [Accepted: 08/08/2022] [Indexed: 01/12/2023]
Abstract
Pretransplantation bariatric surgery in patients with high Model for End-Stage Liver Disease (MELD) score is fraught with risks. Bariatric surgery after liver transplantation (LT) may be complicated by surgical adhesions but could have advantages if performed at the time of transplantation. We investigated a method of brief-interval staging combining LT and sleeve gastrectomy (SG). LT recipients with a body mass index (BMI) > 40 kg/m 2 received an SG during the same hospitalization as the LT (LT/SG), at the same time as a planned brief-interval return to the operating room for biliary anastomosis. Differences in intraoperative attributes of the LT (Stage 1) versus SG (Stage 2) procedures were analyzed using Wilcoxon signed-rank test with significance p < 0.05 and compared with patients with obesity having a two-stage LT without SG. A total of 14 cases {median MELD score 33 (interquartile range [IQR], 18-40)} were compared with 28 controls; 60% were critically ill prior to surgery with mechanical ventilation, vasopressors, or continuous renal replacement therapy. Median interval between procedures was 16.1 (IQR, 12.5-22.7) hours for cases and 12.2 (IQR, 11.1-16.6) hours for controls, p = 0.27. Median BMI at LT/SG was 47.0 (IQR, 41.7-51.3) kg/m 2 versus 38.1 (IQR, 35.7-39.8) kg/m 2 for controls, p < 0.001. At 1 year, median excess body weight loss was 74.0% (IQR, 46.2%-78.7%) in cases and 15.8% (IQR, -5.4% to 62.6%) in controls, p = 0.13; total weight loss was 38.1% (IQR, 23.9-42.9) in cases versus 7.7% (IQR, -2.4% to 27.6%) for controls, p = 0.03. Graft survival at 1 year was 92.9% for cases and 89.3% for controls with similar early postoperative outcomes. This proof-of-concept study revealed that a brief-interval SG during LT is feasible in patients with high MELD and resulted in sustained weight loss at 1 year with similar graft survival. Further studies are needed to determine an optimal strategy.
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Affiliation(s)
- Nabil Tariq
- Department of Surgery , Houston Methodist Hospital , Houston , Texas , USA
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Drenth J, Barten T, Hartog H, Nevens F, Taubert R, Torra Balcells R, Vilgrain V, Böttler T. EASL Clinical Practice Guidelines on the management of cystic liver diseases. J Hepatol 2022; 77:1083-1108. [PMID: 35728731 DOI: 10.1016/j.jhep.2022.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 02/07/2023]
Abstract
The advent of enhanced radiological imaging techniques has facilitated the diagnosis of cystic liver lesions. Concomitantly, the evidence base supporting the management of these diseases has matured over the last decades. As a result, comprehensive clinical guidance on the subject matter is warranted. These Clinical Practice Guidelines cover the diagnosis and management of hepatic cysts, mucinous cystic neoplasms of the liver, biliary hamartomas, polycystic liver disease, Caroli disease, Caroli syndrome, biliary hamartomas and peribiliary cysts. On the basis of in-depth review of the relevant literature we provide recommendations to navigate clinical dilemmas followed by supporting text. The recommendations are graded according to the Oxford Centre for Evidence-Based Medicine system and categorised as 'weak' or 'strong'. We aim to provide the best available evidence to aid the clinical decision-making process in the management of patients with cystic liver disease.
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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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Chang A, Schaubel DE, Chen M, Abt PL, Bittermann T. Trends and Outcomes of Hypothermic Machine Perfusion Preservation of Kidney Allografts in Simultaneous Liver and Kidney Transplantation in the United States. Transpl Int 2022; 35:10345. [PMID: 35356400 PMCID: PMC8958417 DOI: 10.3389/ti.2022.10345] [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: 01/07/2022] [Accepted: 01/18/2022] [Indexed: 11/18/2022]
Abstract
Optimal kidney graft outcomes after simultaneous liver-kidney (SLK) transplant may be threatened by the increased cold ischemia time and hemodynamic perturbations of dual organ transplantation. Hypothermic machine perfusion (MP) of kidney allografts may mitigate these effects. We analyzed U.S. trends and renal outcomes of hypothermic non-oxygenated MP vs. static cold storage (CS) of kidney grafts from 6,689 SLK transplants performed between 2005 and 2020 using the United Network for Organ Sharing database. Outcomes included delayed graft function (DGF), primary non-function (PNF), and kidney graft survival (GS). Overall, 17.2% of kidney allografts were placed on MP. Kidney cold ischemia time was longer in the MP group (median 12.8 vs. 10.0 h; p < 0.001). Nationally, MP utilization in SLK increased from <3% in 2005 to >25% by 2019. Center preference was the primary determinant of whether a graft underwent MP vs. CS (intraclass correlation coefficient 65.0%). MP reduced DGF (adjusted OR 0.74; p = 0.008), but not PNF (p = 0.637). Improved GS with MP was only observed with Kidney Donor Profile Index <20% (HR 0.71; p = 0.030). Kidney MP has increased significantly in SLK in the U.S. in a heterogeneous manner and with variable short-term benefits. Additional studies are needed to determine the ideal utilization for MP in SLK.
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Affiliation(s)
- Alex Chang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Douglas E Schaubel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Melissa Chen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Peter L Abt
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Therese Bittermann
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Truong TT, Nadim MK. Is Prioritization of Kidney Allografts to Combined Liver-Kidney Recipients Appropriate? PRO. KIDNEY360 2021; 3:993-995. [PMID: 35845321 PMCID: PMC9255876 DOI: 10.34067/kid.0001632021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/14/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Tiffany T. Truong
- Division of Nephrology and Hypertension, University of Southern California, Los Angeles, California
| | - Mitra K. Nadim
- Division of Nephrology and Hypertension, University of Southern California, Los Angeles, California
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Goggins WC, Ekser B, Rokop Z, Lutz AJ, Mihaylov P, Mangus RS, Fridell JA, Powelson JA, Kubal CA. Combined liver-kidney transplantation with positive crossmatch: Role of delayed kidney transplantation. Surgery 2021; 170:1240-1247. [PMID: 34092375 DOI: 10.1016/j.surg.2021.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/13/2021] [Accepted: 05/10/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Positive crossmatch (XM+) combined liver-kidney transplantation due to preformed donor-specific human leukocyte antigen antibodies has produced mixed results. We sought to understand the role of delayed kidney transplant approach in XM+ combined liver-kidney transplantations. METHODS XM+ combined liver-kidney transplantations were retrospectively reviewed. T- and B-cell XM, complement-dependent cytotoxic crossmatch, and flow cytometric crossmatch were performed prospectively. RESULTS Of 183 combined liver-kidney transplantations performed (2002-2019), 114 (62%) were with "delayed" kidney transplant approach and 19 (19 of 183, 10%) were XM+. Of 19 XM+ combined liver-kidney transplantations, kidney transplant was "delayed" in 14 by an average of 47 hours (range 24-64 hours) from liver transplant. There was a significant reduction in both class I (mean pre-liver transplant mean fluorescence intensity (MFI) 26,230 versus mean post-liver transplant and pre-delayed kidney transplant MFI 3,272, P = .01) and total MFI (mean pre-liver transplant MFI 27,233 vs mean post liver transplant and predelayed kidney transplant MFI 11,469, P = .01). However, there was no significant change in the MFI of class II donor-specific antibodies (mean pre-liver transplant MFI 17,899 versus post-liver transplant and pre-delayed kidney transplant MFI 14,341, P = .19). None of XM+ delayed kidney transplants had delayed graft function, and there was no antibody-mediated rejection. One-year patient survival for the XM+ combined liver-kidney transplantation with delayed kidney transplant approach was 92.9%, which is comparable to patient survival of XM- combined liver-kidney transplantation. Whereas patient survival in recipients before "delayed" approach ("simultaneous"; n = 5) was 40% when liver-kidney transplants were performed simultaneously (P = .06). CONCLUSION In sensitized combined liver-kidney transplantation recipients, the "delayed" kidney transplant approach is associated with a significant reduction in total and class I donor-specific antibodies after liver transplant before kidney transplant, enabling therapeutic interventions such as plasmapheresis, if needed, providing optimal outcomes similar to crossmatch recipients.
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Affiliation(s)
- William C Goggins
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Burcin Ekser
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. https://twitter.com/BurcinEkser
| | - Zachary Rokop
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Andrew J Lutz
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Plamen Mihaylov
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Richard S Mangus
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. https://twitter.com/RichardMangusMD
| | - Jonathan A Fridell
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. https://twitter.com/jonathanfridell
| | - John A Powelson
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Chandrashekhar A Kubal
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.
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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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Tandoi F, Cussa D, Peruzzi L, Catalano S, Camilla R, Mandrile G, Calvo PL, Pinon M, Dell'Olio D, Salizzoni M, Amoroso A, Romagnoli R. Combined liver kidney transplantation for primary hyperoxaluria type 1: Will there still be a future? Current transplantation strategies and monocentric experience. Pediatr Transplant 2021; 25:e14003. [PMID: 33742750 DOI: 10.1111/petr.14003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 12/13/2022]
Abstract
Combined liver-kidney transplantation is a therapeutic option for children affected by type 1 primary hyperoxaluria. Persistently high plasma oxalate levels may lead to kidney graft failure. It is debated whether pre-emptive liver transplantation, followed by kidney transplantation, might be a better strategy to reduce kidney graft loss. Our experience of 6 pediatric combined liver-kidney transplants for primary hyperoxaluria type 1 in pediatric recipients was retrospectively analyzed. Plasma oxalate levels were monitored before and after transplantation. All the recipients were on hemodialysis at transplantation. Median [IQR] recipient's age at transplantation was 11 [1-14] years; in all cases, a compatible graft from a pediatric brain-dead donor aged 8 [2-16] years was used. In a median follow-up of 7 [2-19] years after combined liver-kidney transplantation, no child died and no liver graft failure was observed; three kidney grafts were lost, due to chronic rejection, primary non-function, and early renal oxalate accumulation. Liver and kidney graft survival remained stable at 1, 3, and 5 years, at 100% and 85%, respectively. Kidney graft loss was the major complication in our series. Risk is higher with very young, low-weight donors. The impact of treatment with glyoxalate pathway enzyme inhibitors treatment in children with advanced disease as well as of donor kidney preservation by ex vivo machine perfusion needs to be evaluated. At present, a case-by-case discussion is needed to establish an optimal treatment strategy.
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Affiliation(s)
- Francesco Tandoi
- General Surgery 2U and Liver Transplant Unit, Department of Surgical Sciences, A.O.U. Città della Salute e della Scienza, Molinette Hospital, University of Torino, Torino, Italy
| | - Davide Cussa
- General Surgery 2U and Liver Transplant Unit, Department of Surgical Sciences, A.O.U. Città della Salute e della Scienza, Molinette Hospital, University of Torino, Torino, Italy
| | - Licia Peruzzi
- Pediatric Nephrology Unit, Department of Pediatrics, A.O.U. Città della Salute e della Scienza, Regina Margherita Children's Hospital, University of Torino, Torino, Italy
| | - Silvia Catalano
- General Surgery 2U and Liver Transplant Unit, Department of Surgical Sciences, A.O.U. Città della Salute e della Scienza, Molinette Hospital, University of Torino, Torino, Italy
| | - Roberta Camilla
- Pediatric Nephrology Unit, Department of Pediatrics, A.O.U. Città della Salute e della Scienza, Regina Margherita Children's Hospital, University of Torino, Torino, Italy
| | - Giorgia Mandrile
- Medical Genetics Unit, Thalassemia Centre, A.O.U. San Luigi, Orbassano, Italy
| | - Pier Luigi Calvo
- Pediatric Gastroenterology Unit, Department of Pediatrics, A.O.U. Città della Salute e della Scienza, Regina Margherita Children's Hospital, University of Torino, Torino, Italy
| | - Michele Pinon
- Pediatric Gastroenterology Unit, Department of Pediatrics, A.O.U. Città della Salute e della Scienza, Regina Margherita Children's Hospital, University of Torino, Torino, Italy
| | - Dominic Dell'Olio
- Regional Transplant Centre, A.O.U. Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Mauro Salizzoni
- General Surgery 2U and Liver Transplant Unit, Department of Surgical Sciences, A.O.U. Città della Salute e della Scienza, Molinette Hospital, University of Torino, Torino, Italy
| | - Antonio Amoroso
- Regional Transplant Centre, A.O.U. Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Renato Romagnoli
- General Surgery 2U and Liver Transplant Unit, Department of Surgical Sciences, A.O.U. Città della Salute e della Scienza, Molinette Hospital, University of Torino, Torino, Italy
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Hobeika MJ, Saharia A, Mobley CM, Menser T, Nguyen DT, Graviss EA, McMillan RR, Podder H, Nolte Fong JV, Jones SL, Yi SG, Elshawwaf M, Gaber AO, Ghobrial RM. Donation after circulatory death liver transplantation: An in-depth analysis and propensity score-matched comparison. Clin Transplant 2021; 35:e14304. [PMID: 33792971 DOI: 10.1111/ctr.14304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 03/14/2021] [Accepted: 03/24/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Careful donor-recipient matching and reduced ischemia times have improved outcomes following donation after circulatory death (DCD) liver transplantation (LT). This study examines a single-center experience with DCD LT including high-acuity and hospitalized recipients. METHODS DCD LT outcomes were compared to a propensity score-matched (PSM) donation after brain death (DBD) LT cohort (1:4); 32 DCD LT patients and 128 PSM DBD LT patients transplanted from 2008 to 2018 were included. Analyses included Kaplan-Meier estimates and Cox proportional hazards models examining patient and graft survival. RESULTS Median MELD score in the DCD LT cohort was 22, with median MELD of 27 for DCD LT recipients with decompensated cirrhosis. No difference in mortality or graft loss was found (p < .05) between DCD LT and PSM DBD LT at 3 years post-transplant, nor was DCD an independent risk factor for patient or graft survival. Post-LT severe acute kidney injury was similar in both groups. Ischemic-type biliary lesions (ITBL) occurred in 6.3% (n = 2) of DCD LT recipients, resulting in 1 graft loss and 1 death. CONCLUSION This study supports that DCD LT outcomes can be similar to DBD LT, with a low rate of ITBL, in a cohort including high-acuity recipients. Strict donor selection criteria, ischemia time minimization, and avoiding futile donor/recipient combinations are essential considerations.
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Affiliation(s)
- Mark J Hobeika
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA.,Department of Surgery, Weill Cornell Medical College, New York, New York, USA.,Center for Outcomes Research, Houston Methodist, Houston, Texas, USA
| | - Ashish Saharia
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA.,Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Constance M Mobley
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA.,Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Terri Menser
- Center for Outcomes Research, Houston Methodist, Houston, Texas, USA.,Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist, Houston, Texas, USA
| | - Edward A Graviss
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA.,Department of Pathology and Genomic Medicine, Houston Methodist, Houston, Texas, USA
| | - Robert R McMillan
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA
| | - Hemangshu Podder
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA
| | - Joy V Nolte Fong
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA
| | - Stephen L Jones
- Department of Surgery, Weill Cornell Medical College, New York, New York, USA.,Center for Outcomes Research, Houston Methodist, Houston, Texas, USA
| | - Stephanie G Yi
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA.,Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Mahmoud Elshawwaf
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA
| | - Ahmed O Gaber
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA.,Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Rafik M Ghobrial
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA.,Department of Surgery, Weill Cornell Medical College, New York, New York, USA
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14
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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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15
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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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16
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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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17
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Ekser B, Contreras AG, Andraus W, Taner T. Current status of combined liver-kidney transplantation. Int J Surg 2020; 82S:149-154. [PMID: 32084547 DOI: 10.1016/j.ijsu.2020.02.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 02/07/2020] [Indexed: 01/07/2023]
Abstract
Combined liver-kidney transplantation is a life-saving procedure for patients with end-stage liver disease and underlying chronic kidney disease, or prolonged acute kidney injury. Due to physiologic changes secondary to portal hypertension in patients with end-stage liver disease, kidney injury is common, and combined liver-kidney transplantation accounts for 10% of all the liver transplants performed in the United States. Recently implemented policy in the United States standardizes the medical criteria for eligibility, and introduces a 'safety net' for those who are transplanted with a liver graft alone, in order to be able to receive a kidney graft later. Increasing number of combined liver-kidney transplants provides a large cohort of patients to be studied in detail for identification of factors (both donor and recipient-related) associated with better outcomes. Data regarding the safety and efficacy of delaying the kidney transplant part of the combined liver-kidney transplantation, and the immunologic benefits of the multi-organ transplantations including the liver are emerging. Here, we review the most recent analyses, and provide our opinion regarding the best practices in combined liver-kidney transplantation based on the evidence.
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Affiliation(s)
- Burcin Ekser
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Alan G Contreras
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico.
| | - Wellington Andraus
- Digestive Organs Transplant Division, Gastroenterology Department, Sao Paulo University School of Medicine, Sao Paulo, Brazil.
| | - Timucin Taner
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, USA; Department Immunology, Mayo Clinic, Rochester, MN, USA.
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18
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Rapid reduction of high-level pre-formed donor-specific antibodies after simultaneous liver-kidney transplantation: a report of two cases. BMC Nephrol 2020; 21:47. [PMID: 32050922 PMCID: PMC7014704 DOI: 10.1186/s12882-020-01714-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/07/2020] [Indexed: 01/27/2023] Open
Abstract
Background Kidney transplantation performed in the presence of high-titre donor-specific antibodies (DSA) may result in hyper-acute or accelerated antibody-mediated rejection and rapid allograft loss. Previous studies have shown that this risk may be mitigated with simultaneous liver-kidney transplantation (SLKT); however, the mechanisms are not well defined. Here we report the evolution of pre-formed, high-level DSAs in two highly sensitised SLKT recipients peri-operatively and describe a profound sustained depletion of all DSAs from the time of liver anastomosis with no extra desensitisation therapy required. Case presentation Two patients underwent SLKT and received our centre’s standard renal transplant immunosuppression with basiliximab and methylprednisolone for induction therapy and prednisolone, mycophenolate and tacrolimus for maintenance therapy. HLA antibody samples were collected pre-operatively, and immediately post-liver and post-kidney revascularisation, and then regularly in the post-transplant period. Complement Dependant Cytotoxicity (CDC) crossmatches were also performed. Both patients were highly sensitised with a PRA over 97%. One patient had a positive B- and T-cell crossmatch pre-transplant. These positive CDC crossmatches became negative and the level of pre-formed DSAs reduced profoundly and rapidly, within 3 h post-liver revascularisation. The reduction in pre-formed DSAs, regardless of subclass, was seen immediately post-liver revascularisation, before implantation of the renal allografts. No significant reduction in non-donor specific HLA-antibodies was observed. Both patients maintained good graft function with no rejection on kidney allograft protocol biopsies performed at 10-weeks post-transplant. Conclusions These cases support the protective immunoregulatory role of the liver in the setting of SLKT, with no extra desensitisation treatment given pre-operatively for these highly sensitised patients.
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