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Cillo U, Carraro A, Avolio AW, Cescon M, Di Benedetto F, Giannelli V, Magistri P, Nicolini D, Vivarelli M, Lanari J. Immunosuppression in liver transplant oncology: position paper of the Italian Board of Experts in Liver Transplantation (I-BELT). Updates Surg 2024; 76:725-741. [PMID: 38713396 DOI: 10.1007/s13304-024-01845-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/31/2023] [Indexed: 05/08/2024]
Abstract
Liver transplant oncology (TO) represents an area of increasing clinical and scientific interest including a heterogeneous group of clinical-pathological settings. Immunosuppressive management after LT is a key factor relevantly impacting result. However, disease-related guidance is still lacking, and many open questions remain in the field. Based on such a substantial lack of solid evidences, the Italian Board of Experts in Liver Transplantation (I-BELT) (a working group including representatives of all national transplant centers), unprecedently promoted a methodologically sound consensus conference on the topic, based on the GRADE approach. The group final recommendations are herein presented and commented. The 18 PICOs and Statements and their levels of evidence and grades of recommendation are reported and grouped into seven areas: (1) risk stratification by histopathological and bio-molecular parameters and role of mTORi post-LT; (2) steroids and HCC recurrence; (3) management of immunosuppression when HCC recurs after LT; (4) mTORi monotherapy; (5) machine perfusion and HCC recurrence after LT; (6) physiopathology of tumor-infiltrating lymphocytes and immunosuppression, the role of inflammation; (7) immunotherapy in liver transplanted patients. The interest in mammalian targets of rapamycin inhibitors (mTORi), for steroid avoidance and the need for a reduction to CNI exposure emerged from the consensus process. A selected list of unmet needs prompting further investigations have also been developed. The so far heterogeneous and granular approach to immunosuppression in oncologic patients deserves greater efforts for a more standardized therapeutic response to the different clinical scenarios. This consensus process makes a first unprecedented step in this direction, to be developed on a larger scale.
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Affiliation(s)
- Umberto Cillo
- Department of Surgical, Oncological and Gastroenterological Sciences, General Surgery 2 Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Padua University Hospital, Via Giustiniani 2, 34128, Padua, PD, Italy.
| | - Amedeo Carraro
- Liver Transplant Unit, Department of Surgery and Oncology, University Hospital Trust of Verona, Verona, Italy
| | - Alfonso W Avolio
- Department of General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Matteo Cescon
- General Surgery and Transplantation Unit, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria-Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Fabrizio Di Benedetto
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Valerio Giannelli
- Liver Unit, Department of Liver Transplant, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Paolo Magistri
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Daniele Nicolini
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Jacopo Lanari
- Department of Surgical, Oncological and Gastroenterological Sciences, General Surgery 2 Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Padua University Hospital, Via Giustiniani 2, 34128, Padua, PD, Italy
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Sharma P, Xie J, Wang L, Zhang M, Magee J, Answine A, Barman P, Jo J, Sinha J, Schluger A, Perreault GJ, Walters KE, Cullaro G, Wong R, Filipek N, Biggins SW, Lai JC, VanWagner LB, Verna EC, Patel YA. Burden of early hospitalization after simultaneous liver-kidney transplantation: Results from the US Multicenter SLKT Consortium. Liver Transpl 2022; 28:1756-1765. [PMID: 35665591 PMCID: PMC11068063 DOI: 10.1002/lt.26523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 04/26/2022] [Accepted: 05/18/2022] [Indexed: 01/13/2023]
Abstract
The burden of early hospitalization (within 6 months) following simultaneous liver-kidney transplant (SLKT) is not known. We examined risk factors associated with early hospitalization after SLKT and their impact on patient mortality conditional on 6-month survival. We used data from the US Multicenter SLKT Consortium cohort study of all adult SLKT recipients between 2002 and 2017 who were discharged alive following SLKT. We used Poisson regression to model rates of early hospitalizations after SLKT. Cox regression was used to identify risk factors associated with mortality conditional on survival at 6 months after SLKT. Median age (N = 549) was 57.7 years (interquartile range [IQR], 50.6-63.9) with 63% males and 76% Whites; 33% had hepatitis C virus, 20% had non-alcohol-associated fatty liver disease, 23% alcohol-associated liver disease, and 24% other etiologies. Median body mass index (BMI) and Model for End-Stage Liver Disease-sodium scores were 27.2 kg/m2 (IQR, 23.6-32.2 kg/m2 ) and 28 (IQR, 23-34), respectively. Two-thirds of the cohort had at least one hospitalization within the first 6 months of SLKT. Age, race, hospitalization at SLKT, diabetes mellitus, BMI, and discharge to subacute rehabilitation (SAR) facility after SLKT were independently associated with a high incidence rate ratio of early hospitalization. Number of hospitalizations within the first 6 months did not affect conditional survival. Early hospitalizations after SLKT were very common but did not affect conditional survival. Although most of the risk factors for early hospitalization were nonmodifiable, discharge to SAR after initial SLKT was associated with a significantly higher incidence rate of early hospitalization. Efforts and resources should be focused on identifying SLKT recipients at high risk for early hospitalization to optimize their predischarge care, discharge planning, and long-term follow-up.
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Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jiaheng Xie
- Department of Biostatistics, University of Michigan School of Public Health, Anna Arbor, Michigan, USA
| | - Leyi Wang
- Department of Biostatistics, University of Michigan School of Public Health, Anna Arbor, Michigan, USA
| | - Min Zhang
- Department of Biostatistics, University of Michigan School of Public Health, Anna Arbor, Michigan, USA
| | - John Magee
- Department of Surgery, Michigan Medicine, University of Michigan, Anna Arbor, Michigan, USA
| | - Adeline Answine
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Pranab Barman
- Division of Gastroenterology and Hepatology, University of California, San Diego, California, USA
| | - Jennifer Jo
- Department of Internal Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jasmine Sinha
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Aaron Schluger
- Department of Internal Medicine, Westchester Medical Center, Westchester, New York, USA
| | - Gabriel J. Perreault
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - Kara E. Walters
- Division of Gastroenterology, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Giuseppe Cullaro
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Randi Wong
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Natalia Filipek
- Department of Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Scott W. Biggins
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Lisa B. VanWagner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Elizabeth C. Verna
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - Yuval A. Patel
- Division of Gastroenterology and Hepatology, Duke University, Durham, North Carolina, USA
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Galeev SR, Gautier SV. Risks and ways of preventing kidney dysfunction in drug-induced immunosuppression in solid organ recipients. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2022. [DOI: 10.15825/1995-1191-2022-4-24-38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Immunosuppressive therapy (IMT) is the cornerstone of treatment after transplantation. The goal of immunosuppression is to prevent acute and chronic rejection while maximizing patient survival and long-term graft function. However, the expected effects of IMT must be balanced against the major adverse effects of these drugs and their toxicity. The purpose of this review is to summarize world experience on current immunosuppressive strategies and to assess their effects on renal function.
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Affiliation(s)
- Sh. R. Galeev
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - S. V. Gautier
- Shumakov National Medical Research Center of Transplantology and Artificial Organs; Sechenov University
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Lins PRG, Narciso RC, Ferraz LR, Pereira VG, Ferraz-Neto BH, De Almeida MD, Dos Santos BFC, Dos Santos OFP, Monte JCM, Júnior MSD, Batista MC. Modelling kidney outcomes based on MELD eras - impact of MELD score in renal endpoints after liver transplantation. BMC Nephrol 2022; 23:294. [PMID: 35999518 PMCID: PMC9400232 DOI: 10.1186/s12882-022-02912-6] [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: 08/22/2021] [Accepted: 07/27/2022] [Indexed: 11/17/2022] Open
Abstract
Background Acute kidney injury is a common complication in solid organ transplants, notably liver transplantation. The MELD is a score validated to predict mortality of cirrhotic patients, which is also used for organ allocation, however the influence of this allocation criteria on AKI incidence and mortality after liver transplantation is still uncertain. Methods This is a retrospective single center study of a cohort of patients submitted to liver transplant in a tertiary Brazilian hospital: Jan/2002 to Dec/2013, divided in two groups, before and after MELD implementation (pre-MELD and post MELD). We evaluate the differences in AKI based on KDIGO stages and mortality rates between the two groups. Results Eight hundred seventy-four patients were included, 408 in pre-MELD and 466 in the post MELD era. The proportion of patients that developed AKI was lower in the post MELD era (p 0.04), although renal replacement therapy requirement was more frequent in this group (p < 0.01). Overall mortality rate at 28, 90 and 365 days was respectively 7%, 11% and 15%. The 1-year mortality rate was lower in the post MELD era (20% vs. 11%, p < 0.01). AKI incidence was 50% lower in the post MELD era even when adjusted for clinically relevant covariates (p < 0.01). Conclusion Liver transplants performed in the post MELD era had a lower incidence of AKI, although there were more cases requiring dialysis. 1-year mortality was lower in the post MELD era, suggesting that patient care was improved during this period.
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Affiliation(s)
- Paulo Ricardo Gessolo Lins
- Hospital Israelita Albert Einstein, São Paulo, Brazil. .,Division of Nephrology, Federal University of São Paulo, São Paulo, Brazil.
| | | | | | | | | | | | | | | | | | - Marcelino Souza Durão Júnior
- Hospital Israelita Albert Einstein, São Paulo, Brazil.,Division of Nephrology, Federal University of São Paulo, São Paulo, Brazil
| | - Marcelo Costa Batista
- Hospital Israelita Albert Einstein, São Paulo, Brazil.,Division of Nephrology, Federal University of São Paulo, São Paulo, Brazil.,Division of Nephrology, New England Medical Center, Tufts University, Medford, MA, 02155, USA
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Cederborg A, Norén Å, Barten T, Lindkvist B, Bennet W, Herlenius G, Castedal M, Marschall HU, Åberg F. Renal function after liver transplantation: Real-world experience with basiliximab induction and delayed reduced-dose tacrolimus. Dig Liver Dis 2022; 54:1076-1083. [PMID: 34965904 DOI: 10.1016/j.dld.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/07/2021] [Accepted: 12/09/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Routine use of delayed reduced-dose calcineurin-inhibitor treatment with induction immunosuppression in liver transplantation to minimize post-operative kidney injury is still scarce. AIM To evaluate real-world experience of basiliximab induction with delayed reduced-dose tacrolimus. METHODS In a retrospective cohort study, kidney function was evaluated pre- and postoperatively by measured glomerular filtration rate (mGFR). Adult patients undergoing liver transplantation between 2000 and 2017 were divided into a conventional treatment group (immediate-introduction of tacrolimus, target trough levels 10-15 ng/mL, and corticosteroids, n = 203) and a revised treatment group (basiliximab induction, reduced-dose tacrolimus, target through levels 5-8 ng/mL, delayed until day three, and mycophenolate mofetil 2000 mg/day, n = 343). RESULTS Mean mGFR was similar between groups at wait-listing (85.3 vs 84.1 ml/min/1.73m², p = 0.60), but higher in the revised treatment group at 3 (56.8 vs 63.4 ml/min/1.73m², p = 0.004) and 12 months post-transplant (60.9 vs 69.7 ml/min/1.73m², p<0.001); this difference remained after correcting for multiple confounders and was independent of pre-transplant mGFR. In the revised treatment group, biopsy proven acute rejection rate was lower (38% vs. 21%, p<0.001), and graft-survival better (p = 0.01). CONCLUSION Basiliximab induction with delayed reduced-dose tacrolimus is associated with less kidney injury when compared to standard-dose tacrolimus, without increased risk of rejection, graft loss or death.
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Affiliation(s)
- Anna Cederborg
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, and Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Åsa Norén
- Transplant Institute, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Thijs Barten
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Björn Lindkvist
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, and Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - William Bennet
- Transplant Institute, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gustaf Herlenius
- Transplant Institute, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Maria Castedal
- Transplant Institute, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hanns-Ulrich Marschall
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, and Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Fredrik Åberg
- Transplant Institute, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Transplantation and Liver Surgery Clinic, Helsinki University Hospital and University of Helsinki, Finland
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Wiseman AC. CKD in Recipients of Nonkidney Solid Organ Transplants: A Review. Am J Kidney Dis 2021; 80:108-118. [PMID: 34979161 DOI: 10.1053/j.ajkd.2021.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 10/25/2021] [Indexed: 12/14/2022]
Abstract
Chronic kidney disease (CKD) after solid organ transplant is a common clinical presentation, affecting 10% to 20% of liver, heart and lung transplant recipients and accounting for approximately 5% of the kidney transplant waiting list. The causes of CKD are different for different types of transplants and are not all, or even predominantly, due to calcineurin inhibitor toxicity, with significant heterogeneity particularly in liver transplant recipients. Many solid organ transplant recipients with advanced CKD benefit from kidney transplantation, but have a higher rate of death while waitlisted and higher mortality following transplant than the general kidney failure population. Recent organ allocation policies and proposals have attempted to address the appropriate identification and prioritization of candidates in need of a kidney transplant, either simultaneous with or following non-kidney transplant. Future research should focus on predictive factors for individuals identified at high risk for progression to kidney failure and death, and strategies to preserve kidney function and minimize the CKD burden in this unique patient population.
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Sharma P, Sui Z, Zhang M, Magee JC, Barman P, Patel Y, Schluger A, Walter K, Biggins SW, Cullaro G, Wong R, Lai JC, Jo J, Sinha J, VanWagner L, Verna EC. Renal Outcomes After Simultaneous Liver-Kidney Transplantation: Results from the US Multicenter Simultaneous Liver-Kidney Transplantation Consortium. Liver Transpl 2021; 27:1144-1153. [PMID: 33641218 PMCID: PMC8823286 DOI: 10.1002/lt.26032] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/29/2020] [Accepted: 01/26/2021] [Indexed: 12/19/2022]
Abstract
Simultaneous liver-kidney transplantation (SLKT) is increasingly common in the United States. However, little is known about the renal-related outcomes following SLKT, which are essential to maximize the health of these allografts. We examined the factors impacting renal function following SLKT. This is an observational multicenter cohort study from the US Multicenter SLKT Consortium consisting of recipients of SLKT aged ≥18 years of transplantations performed between February 2002 and June 2017 at 6 large US centers in 6 different United Network for Organ Sharing regions. The primary outcome was incident post-SLKT stage 4-5 chronic kidney disease (CKD) defined as <30 mL/minute/1.73 m2 or listing for kidney transplant. The median age of the recipients (n = 570) was 58 years (interquartile range, 51-64 years), and 37% were women, 76% were White, 33% had hepatitis C virus infection, 20% had nonalcoholic steatohepatitis (NASH), and 23% had alcohol-related liver disease; 68% developed ≥ stage 3 CKD at the end of follow-up. The 1-year, 3-year, and 5-year incidence rates of post-SLKT stage 4-5 CKD were 10%, 12%, and 16%, respectively. Pre-SLKT diabetes mellitus (hazard ratio [HR], 1.45; 95% CI, 1.00-2.15), NASH (HR, 1.58; 95% CI, 1.01-2.45), and delayed kidney graft function (HR, 1.72; 95% CI, 1.10-2.71) were the recipient factors independently associated with high risk, whereas the use of tacrolimus (HR, 0.44; 95% CI, 0.22-0.89) reduced the risk. Women (β = -6.22 ± 2.16 mL/minute/1.73 m2 ; P = 0.004), NASH (β = -7.27 ± 3.27 mL/minute/1.73 m2 ; P = 0.027), and delayed kidney graft function (β = -7.25 ± 2.26 mL/minute/1.73 m2 ; P = 0.007) were independently associated with low estimated glomerular filtration rate at last follow-up. Stage 4-5 CKD is common after SLKT. There remains an unmet need for personalized renal protective strategies, specifically stratified by sex, diabetes mellitus, and liver disease, to preserve renal function among SLKT recipients.
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Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI
| | - Zhiyu Sui
- Department of Biostatistics, School of Public Health, Michigan Medicine, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, Michigan Medicine, Ann Arbor, MI
| | - John C. Magee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Pranab Barman
- Division of Gastroenterology and Hepatology, University of California, San Diego, CA
| | - Yuval Patel
- Division of Gastroenterology, Duke University, Durham, NC
| | - Aaron Schluger
- Section of Internal Medicine, Westchester Medical Center, Westchester, NY
| | - Kara Walter
- Division of Digestive Diseases, University of California, Los Angeles, CA
| | - Scott W. Biggins
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, WA
| | - Giuseppe Cullaro
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY
| | - Randi Wong
- Division of Gastroenterology and Hepatology, University of California, San Francisco, CA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, CA
| | - Jennifer Jo
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | - Jasmine Sinha
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | - Lisa VanWagner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY
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YANKOL Y, BUGEAUD E, ZENS T, RIZZARI M, MECİT N, E. LEVERSON G, FOLEY D, D. MEZRICH J, KANMAZ T, M. ANDAÇOĞLU O, M. D’ALESSANDRO A, S. ACARLI K, KALAYOĞLU M, A. FERNANDEZ L. A comparison of rates and severity of chronic kidney disease in deceased-donor and living-donor liver transplant recipients: times matter. Turk J Med Sci 2021; 51:610-622. [PMID: 33037873 PMCID: PMC8203160 DOI: 10.3906/sag-2007-82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 10/09/2020] [Indexed: 11/08/2022] Open
Abstract
Background/aim The progression of chronic kidney disease (CKD) in recipients of living-donor liver transplant (LDLT) compared to deceased-donor liver transplant (DDLT) has not been studied in the literature. We hypothesize that CKD stage progression in LDLT recipients is reduced compared to that of their DDLT counterparts. Materials and methods A retrospective study was undertaken including 999 adult, single-organ, primary liver transplant recipients (218 LDLT and 781 DDLT) at 2 centers between January 2003 and December 2012, in which CKD progression and regression were evaluated within the first 3 years after transplantation. Results Waiting time from evaluation to transplantation was significantly lower in LDLT patients compared to recipients of DDLT. CKD stage progression from preoperative transplant evaluation to transplantation was significantly greater in DDLT. Deceased-donor liver transplant recipients continued to have higher rates of clinically significant renal disease progression (from stage I–II to stage III–V) across multiple time points over the first 3 years posttransplant. Furthermore, a greater degree of CKD regression was observed in recipients of LDLT. Conclusion It can be concluded that LDLT provides excellent graft and patient survival, significantly reducing the overall incidence of clinically significant CKD stage progression when compared to DDLT. Moreover, there is a significantly higher incidence of CKD stage regression in LDLT compared to DDLT. These observations were maintained in both high and low model for end-stage liver disease(MELD)populations. This observation likely reflects earlier access to transplantation in LDLT as one of the contributing factors to preventing CKD progression.
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Affiliation(s)
- Yücel YANKOL
- Department of Surgery–Division of Transplantation, School of Medicine and Public Health, University of Wisconsin, Madison, WIUSA
- Organ Transplant Center, Memorial Şişli Hospital, İstanbulTurkey
| | - Emily BUGEAUD
- Department of Surgery–Division of Transplantation, School of Medicine and Public Health, University of Wisconsin, Madison, WIUSA
- Multi-Organ Transplant Institute, Ochsner Health System, New Orleans, LAUSA
| | - Tiffany ZENS
- Department of Surgery–Division of Transplantation, School of Medicine and Public Health, University of Wisconsin, Madison, WIUSA
| | - Michael RIZZARI
- Department of Surgery–Division of Transplantation, School of Medicine and Public Health, University of Wisconsin, Madison, WIUSA
- Transplant Institute, Henry Ford Health System, Detroit, MIUSA
| | - Nesimi MECİT
- Organ Transplant Center, Memorial Şişli Hospital, İstanbulTurkey
- Organ Transplant Center, School of Medicine, Koç University, İstanbulTurkey
| | - Glen E. LEVERSON
- Department of Surgery–Biostatistics, School of Medicine and Public Health, University of Wisconsin, Madison, WIUSA
| | - David FOLEY
- Department of Surgery–Division of Transplantation, School of Medicine and Public Health, University of Wisconsin, Madison, WIUSA
| | - Joshua D. MEZRICH
- Department of Surgery–Division of Transplantation, School of Medicine and Public Health, University of Wisconsin, Madison, WIUSA
| | - Turan KANMAZ
- Organ Transplant Center, Memorial Şişli Hospital, İstanbulTurkey
- Organ Transplant Center, School of Medicine, Koç University, İstanbulTurkey
| | - Oya M. ANDAÇOĞLU
- Department of Surgery–Division of Transplantation, School of Medicine and Public Health, University of Wisconsin, Madison, WIUSA
- Organ Transplant Center, School of Medicine, Koç University, İstanbulTurkey
| | - Anthony M. D’ALESSANDRO
- Department of Surgery–Division of Transplantation, School of Medicine and Public Health, University of Wisconsin, Madison, WIUSA
| | - Koray S. ACARLI
- Organ Transplant Center, Memorial Şişli Hospital, İstanbulTurkey
| | - Münci KALAYOĞLU
- Organ Transplant Center, Memorial Şişli Hospital, İstanbulTurkey
- Organ Transplant Center, School of Medicine, Koç University, İstanbulTurkey
| | - Luis A. FERNANDEZ
- Department of Surgery–Division of Transplantation, School of Medicine and Public Health, University of Wisconsin, Madison, WIUSA
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9
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Di Maira T, Little EC, Berenguer M. Immunosuppression in liver transplant. Best Pract Res Clin Gastroenterol 2020; 46-47:101681. [PMID: 33158467 DOI: 10.1016/j.bpg.2020.101681] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/31/2020] [Indexed: 02/07/2023]
Abstract
The increasing potency of immunosuppression (IS) agents resulted in significantly decreased rates of steroid resistant rejection and rejection related graft loss in liver transplantation (LT). Currently, more than two thirds of late mortality after LT is unrelated to graft function. However, the increased benefit of more potent IS drugs, coupled with the prolonged survival of transplant recipients led to longer patients exposure to these drugs and their unwanted adverse effects, creating a double-edged sword. In this article the authors describe the mechanism of action and the adverse effects of the most commonly used immunosuppressed drugs, and the most commonly used IS regimens for both induction and maintenance regimens. The balance between the ideal IS regimen to prevent rejection and the need to minimize the dose of IS drugs in order to prevent the adverse effects related to its use requires the knowledge of the science and the experience with the art of medicine. The different protocols aimed at protecting renal function and preventing the development of de novo cancer and metabolic syndrome are discussed here. The main causes of mortality late after liver transplant are associated with prolonged use of IS medications, and clear evidence exists about over-immunosuppression of recipients of liver transplant. The current status of strategies of IS minimization and withdrawal are reviewed in this article, with evaluation of its benefits and pitfalls.
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Affiliation(s)
- Tommaso Di Maira
- Liver Transplantation and Hepatology Unit, Hospital Universitari I Politècnic La Fe, Avda Fernando Abril Martorell, 106 (Torre F5), Valencia, 46026, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, 28029, Spain; ISS La Fe, Valencia, 46026, Spain.
| | - Ester Coelho Little
- University of Arizona, College of Medicine, 3110 East Minnesona Avenue, Phoenix, AZ, 85016, USA.
| | - Marina Berenguer
- Liver Transplantation and Hepatology Unit, Hospital Universitari I Politècnic La Fe, Avda Fernando Abril Martorell, 106 (Torre F5), Valencia, 46026, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, 28029, Spain; ISS La Fe, Valencia, 46026, Spain; Universidad de Valencia, Facultad de Medicina, Valencia, 46010, Spain.
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