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Zhang IW, Lurje I, Lurje G, Knosalla C, Schoenrath F, Tacke F, Engelmann C. Combined Organ Transplantation in Patients with Advanced Liver Disease. Semin Liver Dis 2024; 44:369-382. [PMID: 39053507 PMCID: PMC11449526 DOI: 10.1055/s-0044-1788674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Transplantation of the liver in combination with other organs is an increasingly performed procedure. Over the years, continuous improvement in survival could be realized through careful patient selection and refined organ preservation techniques, in spite of the challenges posed by aging recipients and donors, as well as the increased use of steatotic liver grafts. Herein, we revisit the epidemiology, allocation policies in different transplant zones, indications, and outcomes with regard to simultaneous organ transplants involving the liver, that is combined heart-liver, liver-lung, liver-kidney, and multivisceral transplantation. We address challenges surrounding combined organ transplantation such as equity, utility, and logistics of dual organ implantation, but also advantages that come along with combined transplantation, thereby focusing on molecular mechanisms underlying immunoprotection provided by the liver to the other allografts. In addition, the current standing and knowledge of machine perfusion in combined organ transplantation, mostly based on center experience, will be reviewed. Notwithstanding all the technical advances, shortage of organs, and the lack of universal eligibility criteria for certain multi-organ combinations are hurdles that need to be tackled in the future.
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Affiliation(s)
- Ingrid Wei Zhang
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin, Berlin, Germany
- European Foundation for the Study of Chronic Liver Failure (EF CLIF) and Grifols Chair, Barcelona, Spain
| | - Isabella Lurje
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Georg Lurje
- Department of Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Cornelius Engelmann
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin, Berlin, Germany
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Kaufman DM, Perkins JD, Bakthavatsalam R, Leca N, Sibulesky L. Simultaneous Liver and Kidney Transplantation in Patients Aged 70 y and Older: Proceed With Caution. Transplant Direct 2024; 10:e1683. [PMID: 39035115 PMCID: PMC11259391 DOI: 10.1097/txd.0000000000001683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/30/2024] [Indexed: 07/23/2024] Open
Abstract
Background The number of elderly patients aged 70 y and older with liver and kidney failure is increasing, mainly because of increasing prevalence of metabolic dysfunction-associated steatohepatitis. At present, limited data are available on the outcomes of elderly patients who fit the criteria for dual organ transplantation since the implementation of the simultaneous liver and kidney (SLK) allocation policy. Methods We performed a retrospective analysis of the Organ Procurement and Transplantation Network database of adults aged 18 y and older undergoing SLK and kidney transplantation only from August 11, 2017, to December 31, 2022. We examined patient and graft survivals and compared the outcomes of the recipients aged 70 y and older undergoing SLK transplantation to those who received kidney transplant alone and kidney after liver transplant. Results During the study period, there has been a significant rise in the number of patients aged 70 y and older undergoing SLK transplantation, with 6 patients undergoing SLK transplantation in 2017 and 63 in 2021. Patients aged 70 y and older had significantly lower survival with 82.9% at 1 y and 66.5% at 3 y compared with 89.3% and 78.8% in the 50-69 y age group and 93.2% and 88.6% in the 18-49 y age group, respectively. Overall, kidney allograft survival was significantly lower in the 70 y and older group, with 80.9% at 1 y and 66.4% at 3 y compared with 91.1% and 75.5%, respectively, in those undergoing kidney transplant alone. There was no difference in kidney allograft survival in those undergoing SLK and kidney after liver transplantation. Conclusions Although the outcomes are inferior in recipients of SLK transplant aged 70 y and older, chronologic age should not preclude them from undergoing transplantation. Kidney transplantation after liver transplantation could be considered to avoid futile transplants.
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Affiliation(s)
- Daniel M. Kaufman
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - James D. Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, WA
| | - Ramasamy Bakthavatsalam
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Nicolae Leca
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, WA
- Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Lena Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, WA
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3
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Attieh RM, Ibrahim RM, Ghali P, Keaveny A, Croome K, Hodge D, White L, Wadei HM. Improved outcomes of kidney after liver transplantation after the implementation of the safety net policy. Liver Transpl 2024; 30:582-594. [PMID: 38015446 DOI: 10.1097/lvt.0000000000000302] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023]
Abstract
The number of kidney after liver transplants (KALT) increased after the implementation of the United Network of Organ Sharing (UNOS) safety net policy, but the effects of the policy on KALT outcomes remain unknown. Using the UNOS database, we identified KALT between 60 and 365 days from liver transplant from January 1, 2010, to December 31, 2020. The main outcome was 1- and 3-year patient, liver, and kidney graft survival. Secondary outcomes included 6-month and 1-year acute rejection (AR) of liver and kidney, and 1-year kidney allograft function. Of the 256 KALT, 90 were pre-policy and 166 post-policy. Compared to pre-policy, post-policy 1- and 3-year liver graft survival was higher (54% and 54% vs. 86% and 81%, respectively, p <0.001), while 1- and 3-year kidney graft survival (99% and 75% vs. 92% and 79%, respectively, p =0.19), and 1- and 3-year patient survival (99% and 99% vs. 95% and 89%, respectively, p =0.11) were not significantly different. Subgroup analysis revealed similar trends in patients with and without renal failure at liver transplant. Liver AR at 6 months was lower post-policy (6.3% vs. 18.3%, p =0.006) but was similar (10.5% vs. 13%, p =0.63) at 1 year. Kidney AR was unchanged post-policy at 6 months and 1 year. Creatinine at 1 year did not differ post-policy versus pre-policy (1.4 vs. 1.3 mg/dL, p =0.07) despite a higher proportion of deceased donors, higher Kidney Donor Profile Index, and longer kidney cold ischemia time post-policy ( p <0.05 for all). This 3-year follow-up after the 2017 UNOS policy revision demonstrated that the safety net implementation has resulted in improved liver outcomes for patients who underwent KALT with no increased AR of the liver or the kidney allografts.
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Affiliation(s)
- Rose Mary Attieh
- Department of Transplant, Mayo Clinic, Jacksonville, Florida, USA
- Department of Medicine, Division of Kidney Diseases and Hypertension, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Ramez M Ibrahim
- Department of Transplant, Mayo Clinic, Jacksonville, Florida, USA
| | - Peter Ghali
- Department of Medicine, Division of Gastroenterology, University of Florida, Gainesville, Florida, USA
| | - Andrew Keaveny
- Department of Transplant, Mayo Clinic, Jacksonville, Florida, USA
| | | | - David Hodge
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Launia White
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Hani M Wadei
- Department of Transplant, Mayo Clinic, Jacksonville, Florida, USA
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4
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Gonzalez SA, Asrani SK. Priority for kidney after liver transplantation: A safety net for all? Liver Transpl 2024; 30:563-564. [PMID: 38421950 DOI: 10.1097/lvt.0000000000000354] [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] [Received: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Stevan A Gonzalez
- Division of Hepatology, Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White All Saints Medical Center Fort Worth, Fort Worth, Texas, USA
- Department of Medicine, Burnett School of Medicine at TCU, Fort Worth, Texas, USA
| | - Sumeet K Asrani
- Division of Hepatology, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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Lum EL, Bunnapradist S, Wiseman AC, Gurakar A, Ferrey A, Reddy U, Al Ammary F. Novel indications for referral and care for simultaneous liver kidney transplant recipients. Curr Opin Nephrol Hypertens 2024; 33:354-360. [PMID: 38345405 PMCID: PMC10990015 DOI: 10.1097/mnh.0000000000000970] [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] [Indexed: 03/20/2024]
Abstract
PURPOSE OF REVIEW Kidney dysfunction is challenging in liver transplant candidates to determine whether it is reversible or not. This review focuses on the pertinent data on how to best approach liver transplant candidates with kidney dysfunction in the current era after implementing the simultaneous liver kidney (SLK) allocation policy and safety net. RECENT FINDINGS The implementation of the SLK policy inverted the steady rise in SLK transplants and improved the utilization of high-quality kidneys. Access to kidney transplantation following liver transplant alone (LTA) increased with favorable outcomes. Estimating GFR in liver transplant candidates remains challenging, and innovative methods are needed. SLK provided superior patient and graft survival compared to LTA only for patients with advanced CKD and dialysis at least 3 months. SLK can provide immunological protection against kidney rejection in highly sensitized candidates. Post-SLK transplant care is complex, with an increased risk of complications and hospitalization. SUMMARY The SLK policy improved kidney access and utilization. Transplant centers are encouraged, under the safety net, to reserve SLK for liver transplant candidates with advanced CKD or dialysis at least 3 months while allowing lower thresholds for highly sensitized patients. Herein, we propose a practical approach to liver transplant candidates with kidney dysfunction.
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Affiliation(s)
- Erik L. Lum
- Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - Suphamai Bunnapradist
- Department of Medicine, University of California Los Angeles, Los Angeles, California
| | | | - Ahmet Gurakar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Antoney Ferrey
- Department of Medicine, University of California Irvine, Orange, California, USA
| | - Uttam Reddy
- Department of Medicine, University of California Irvine, Orange, California, USA
| | - Fawaz Al Ammary
- Department of Medicine, University of California Irvine, Orange, California, USA
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Jain R, Kittleson MM. Evolutions in Combined Heart-Kidney Transplant. Curr Heart Fail Rep 2024; 21:139-146. [PMID: 38231443 PMCID: PMC10923997 DOI: 10.1007/s11897-024-00646-0] [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] [Accepted: 01/08/2024] [Indexed: 01/18/2024]
Abstract
PURPOSE OF REVIEW This review describes management practices, outcomes, and allocation policies in candidates for simultaneous heart-kidney transplantation (SHKT). RECENT FINDINGS In patients with heart failure and concomitant kidney disease, SHKT confers a survival advantage over heart transplantation (HT) alone in patients with dialysis dependence or an estimated glomerular filtration rate (eGFR) < 40 mL/min/1.73 m2. However, when compared to kidney transplantation (KT) alone, SHKT is associated with worse patient and kidney allograft survival. In September 2023, the United Network of Organ Sharing adopted a new organ allocation policy, with strict eligibility criteria for SHKT and a safety net for patients requiring KT after HT alone. While the impact of the policy change on SHKT outcomes remains to be seen, strategies to prevent and slow development of kidney disease in patients with heart failure and to prevent kidney dysfunction after HT and SHKT are necessary.
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Affiliation(s)
- Rashmi Jain
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, 2nd floor, 8670 Wilshire Boulevard, Los Angeles, CA, 90211, USA
| | - Michelle M Kittleson
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, 2nd floor, 8670 Wilshire Boulevard, Los Angeles, CA, 90211, USA.
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Kumar A, Wadei HM. Kidney after Liver Transplantation for All: Are You Kidneying Me? Clin J Am Soc Nephrol 2024; 19:289-291. [PMID: 38265809 PMCID: PMC10937010 DOI: 10.2215/cjn.0000000000000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Affiliation(s)
- Abhishek Kumar
- Section of Nephrology, Yale School of Medicine, New Haven, Connecticut
| | - Hani M. Wadei
- Department of Transplant, Mayo Clinic, Jacksonville, Florida
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Tanaka T, Lentine KL, Shi Q, Vander Weg M, Axelrod DA. Differential Impact of the UNOS Simultaneous Liver-kidney Transplant Policy Change Among Patients With Sustained Acute Kidney Injury. Transplantation 2024; 108:724-731. [PMID: 37677960 DOI: 10.1097/tp.0000000000004774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Simultaneous liver-kidney transplant (SLK) allocation policy in the United States was revised in August 2017, reducing access for liver transplant candidates with sustained acute kidney injury (sAKI) and potentially adversely impacting vulnerable populations whose true renal function is overestimated by commonly used estimation equations. METHODS We examined national transplant registry data containing information for all liver transplant recipients from June 2013 to December 2021 to assess the impact of this policy change using instrumental variable estimation based on date of listing. RESULTS Posttransplant survival was compared for propensity-matched patients with sAKI who were only eligible for liver transplant alone (LTA_post; n = 638) after the policy change but would have been SLK-eligible before August 2017, with similar patients who were previously able to receive an SLK (SLK; n = 319). Overall posttransplant patient survival was similar at 3 y (81% versus 80%; P = 0.9). However, receiving an SLK versus LTA increased survival among African Americans (87% versus 61% at 3 y; P = 0.029). A trend toward survival benefit from SLK versus LTA, especially later in the follow-up period, was observed in recipients ≥ age 60 (3-y survival: 84% versus 76%; P = 0.2) and women (86% versus 80%; P = 0.2). CONCLUSIONS The 2017 United Network for Organ Sharing SLK Allocation Policy was associated with reduced survival of African Americans with end-stage liver disease and sAKI and, potentially, older patients and women. Our study suggested the use of race-neutral estimation of renal function would ameliorate racial disparities in the SLK arena; however, further studies are needed to reduce disparity in posttransplant outcomes among patients with liver and kidney failure.
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Affiliation(s)
- Tomohiro Tanaka
- Division of Gastroenterology and Hepatology, University of Iowa Carver College of Medicine, Iowa City, IA
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA
- University of Iowa Carver College of Medicine, Iowa City, IA
| | - Krista L Lentine
- Saint Louis University Transplant Center, SSM-Saint Louis University Hospital, St. Louis, MO
| | - Qianyi Shi
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA
- University of Iowa Carver College of Medicine, Iowa City, IA
| | - Mark Vander Weg
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, IA
| | - David A Axelrod
- Division of Transplantation and Hepatobiliary Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
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Schold JD, Mohan S, Jackson WE, Stites E, Burton JR, Bababekov YJ, Saben JL, Pomposelli JJ, Pomfret EA, Kaplan B. Differential in Kidney Graft Years on the Basis of Solitary Kidney, Simultaneous Liver-Kidney, and Kidney-after-Liver Transplants. Clin J Am Soc Nephrol 2024; 19:364-373. [PMID: 37962880 PMCID: PMC10937020 DOI: 10.2215/cjn.0000000000000353] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/07/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND The number of simultaneous liver-kidney (SLK) transplants has significantly increased in the United States. There has also been an increase in kidney-after-liver transplants associated with 2017 policy revisions aimed to fairly allocate kidneys after livers. SLK and kidney-after-liver candidates are prioritized in allocation policy for kidney offers ahead of kidney-alone candidates. METHODS We compared kidney graft outcomes of kidney-alone transplant recipients with SLK and kidney-after-liver transplants using paired kidney models to mitigate differences among donor risk factors. We evaluated recipient characteristics between transplant types and calculated differential graft years using restricted mean survival estimates. RESULTS We evaluated 3053 paired donors to kidney-alone and SLK recipients and 516 paired donors to kidney-alone and kidney-after-liver recipients from August 2017 to August 2022. Kidney-alone recipients were younger, more likely on dialysis, and Black race. One-year and 3-year post-transplant kidney graft survival for kidney-alone recipients was 94% and 86% versus SLK recipients 89% and 80%, respectively, P < 0.001. One-year and 3-year kidney graft survival for kidney-alone recipients was 94% and 84% versus kidney-after-liver recipients 93% and 87%, respectively, P = 0.53. The additional kidney graft years for kidney-alone versus SLK transplants was 21 graft years/100 transplants (SEM=5.0) within 4 years post-transplantation, with no significant difference between kidney-after-liver and kidney-alone transplants. CONCLUSIONS Over a 5-year period in the United States, SLK transplantation was associated with significantly lower kidney graft survival compared with paired kidney-alone transplants. Most differences in graft survival between SLK and kidney-alone transplants occurred within the first year post-transplantation. By contrast, kidney-after-liver transplants had comparable graft survival with paired kidney-alone transplants.
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Affiliation(s)
- Jesse D. Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Whitney E. Jackson
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Erik Stites
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - James R. Burton
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Yanik J. Bababekov
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jessica L. Saben
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - James J. Pomposelli
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Elizabeth A. Pomfret
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Shaw BI, McElroy LM. Context Is Everything. Transplantation 2024; 108:607-608. [PMID: 37677947 PMCID: PMC10915098 DOI: 10.1097/tp.0000000000004775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Brian I Shaw
- Department of Surgery, Duke University School of Medicine, Durham, NC
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11
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Okumura K, Ohira S, Kai M, Misawa R, Wolfe K, Sogawa H, Veillette G, Nishida S, Spielvogel D, Lansman S, Dhand A. High Rate of Kidney Graft Failure after Simultaneous Heart-Kidney Transplantation. KIDNEY360 2024; 5:252-261. [PMID: 38268085 PMCID: PMC10914208 DOI: 10.34067/kid.0000000000000365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/11/2024] [Indexed: 01/26/2024]
Abstract
Key Points Simultaneous heart–kidney transplant is associated with high rates of kidney graft failure which are worse when compared with kidney transplant alone. The major causes of kidney graft failure in simultaneous heart–kidney transplant recipients were patient death and primary nonfunction of kidney graft. Background The indications and outcomes of simultaneous heart–kidney transplantation (SHKT) remain suboptimally defined. Risk factors for renal graft failure after SHKT also remain poorly defined. Methods We analyzed the renal graft outcomes among SHKT recipients using United Network for Organ Sharing database from 2015 to 2020. To evaluate for factors associated with poor renal outcomes, we compared SHKT and kidney transplantation alone recipients using propensity score matching. Results Among SHKT recipients, the rate of primary nonfunction (PNF) of kidney graft was 3%, the 30-day kidney graft failure rate was 7.0%, and the 30-day post-transplant mortality rate was 4.1%. The incidence of kidney delayed graft function was 27.5%. Kidney graft failure was seen early post-SHKT with most common causes of patient death (43.9%) and PNF of kidney graft (41.5%). One- and 2-year patient survival was 89.2% and 86.5%, and 1- and 2-year freedom from kidney graft failure was 85.4% and 82.7%, respectively. In subgroup analysis of SHKT recipients, use of pretransplant mechanical cardiac support (adjusted odds ratio [aOR], 2.57; P = 0.017), higher calculated panel reactive antibody (aOR, 1.76; P = 0.016), and older donor age per 10 years (aOR, 1.94; P = 0.001) were associated with PNF. Pretransplant extracorporeal membrane oxygenation support was associated with the increased risk of 30-day recipient mortality (aOR, 5.55; P = 0.002). Increased 30-day graft failure was seen in SHKT recipients with pretransplant mechanical cardiac support (aOR, 1.77; P = 0.038) and dialysis at the time of transplant (aOR, 1.72; P = 0.044). Multivariable Cox hazard analysis demonstrated that SHKT, when compared with kidney transplantation alone, is associated with increased kidney graft failure (hazard ratio, 2.56; P < 0.001) and recipient mortality (hazard ratio, 2.65; P < 0.001). Conclusions SHKT is associated with high rates of kidney graft failure. Identification of risk factors of renal graft failure can help optimize recipient selection for SHKT versus kidney after heart transplantation, especially after introduction of the new safety-net policy.
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Affiliation(s)
- Kenji Okumura
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Suguru Ohira
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Masashi Kai
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Ryosuke Misawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Kevin Wolfe
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Hiroshi Sogawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Gregory Veillette
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Seigo Nishida
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - David Spielvogel
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Steven Lansman
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Abhay Dhand
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, New York
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12
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Cheng XS, McElroy LM, Sanoff SL, Kwong AJ. One size does not fit all: Differential benefits of simultaneous liver-kidney transplantation by eligibility criteria. Liver Transpl 2023; 29:1208-1215. [PMID: 37329171 DOI: 10.1097/lvt.0000000000000191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 06/04/2023] [Indexed: 06/18/2023]
Abstract
Standard eligibility criteria for simultaneous liver-kidney transplantation (SLK) are in place in the United States. We hypothesize that the benefit associated with SLK over liver transplant alone differs by patient, depending on the specific SLK criteria met. We analyzed a retrospective US cohort of 5446 adult liver transplant or SLK recipients between January 1, 2015, and December 31, 2018, who are potentially qualified for SLK. Exposure was a receipt of SLK. We tested effect modification by the specific SLK eligibility criteria met (end-stage kidney disease, acute kidney injury, chronic kidney disease, or unknown). The primary outcome was death within 1 year of a liver transplant. We used a modified Cox regression analysis containing an interaction term of SLK * time from transplant. Two hundred ten (9%) SLK recipients and 351 (11%) liver-alone recipients died in 1 year. In the overall population, SLK was associated with a mortality benefit over liver transplant on the day of the transplant, without adjustment [HR: 0.59 (95% CI, 0.46-0.76)] and with adjustment [aHR: 0.50 (95% CI, 0.35-0.71)]. However, when SLK eligibility criteria were included, only in patients with end-stage kidney disease was SLK associated with a sustained survival benefit at day 0 [HR: 0.17 (0.08-0.35)] up to 288 (95% CI, 120-649) days post-transplant. Benefit within the first year post-transplant associated with SLK over liver-alone transplantation was only pronounced in patients with end-stage kidney disease but not present in patients meeting other criteria for SLK. A "strict SLK liberal Safety Net" strategy may warrant consideration at the national policy level.
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Affiliation(s)
- Xingxing S Cheng
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Lisa M McElroy
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Scott L Sanoff
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Allison J Kwong
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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13
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Kittleson MM, Sharma K, Brennan DC, Cheng XS, Chow SL, Colvin M, DeVore AD, Dunlay SM, Fraser M, Garonzik-Wang J, Khazanie P, Korenblat KM, Pham DT. Dual-Organ Transplantation: Indications, Evaluation, and Outcomes for Heart-Kidney and Heart-Liver Transplantation: A Scientific Statement From the American Heart Association. Circulation 2023; 148:622-636. [PMID: 37439224 DOI: 10.1161/cir.0000000000001155] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
Although heart transplantation is the preferred therapy for appropriate patients with advanced heart failure, the presence of concomitant renal or hepatic dysfunction can pose a barrier to isolated heart transplantation. Because donor organ supply limits the availability of organ transplantation, appropriate allocation of this scarce resource is essential; thus, clear guidance for simultaneous heart-kidney transplantation and simultaneous heart-liver transplantation is urgently required. The purposes of this scientific statement are (1) to describe the impact of pretransplantation renal and hepatic dysfunction on posttransplantation outcomes; (2) to discuss the assessment of pretransplantation renal and hepatic dysfunction; (3) to provide an approach to patient selection for simultaneous heart-kidney transplantation and simultaneous heart-liver transplantation and posttransplantation management; and (4) to explore the ethics of multiorgan transplantation.
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14
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Cabeza Rivera FH, Concepcion BP, Levea SLL. Chronic Kidney Disease After Liver Transplantation. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:368-377. [PMID: 37657883 DOI: 10.1053/j.akdh.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
Chronic kidney disease among liver transplant recipients is common and associated with an increased mortality risk. Several risk factors and causes for the development of chronic kidney disease have been identified. They can be divided into perioperative factors, such as unresolved acute kidney injury; donor-related factors, such as the use of extended criteria liver allografts; and recipient-related factors, such as the use of calcineurin inhibitors and the presence of metabolic syndrome, diabetes, and obesity. There is a bimodal progression, more prominent during the initial post-transplant months, followed by a gradual but progressive decline over the subsequent years. Management strategies to prevent and treat chronic kidney disease in the general population can be reasonably applied to the liver transplant population and include addressing comorbidities such as hypertension and diabetes. Strategies to minimize or withdraw calcineurin inhibitors from the immunosuppressive regimen can slow progression of kidney dysfunction. Patients with advanced chronic kidney disease should be considered for kidney transplantation due to its survival advantage. Allocation policy in the United States confers safety-net allocation priority for liver transplant recipients who develop advanced chronic kidney disease within the first year of liver transplantation.
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Affiliation(s)
- Franco H Cabeza Rivera
- Katz Family Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, FL
| | | | - Swee-Ling L Levea
- Division of Nephrology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
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15
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Griffin C, Asrani SK, Regner KR. Update on Assessment of Estimated Glomerular Filtration Rate in Patients With Cirrhosis. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:307-314. [PMID: 37389536 DOI: 10.1053/j.akdh.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 07/01/2023]
Abstract
Kidney disease is associated with adverse outcomes in patients with cirrhosis including increased post-liver transplantation (LT) mortality. Therefore, diagnosis and staging of kidney disease are critical to timely implementation of treatment and have important implications for transplant eligibility. Serum creatinine (sCr) is a key component of the Model for End-Stage Liver Disease score in LT candidates, and sCr-based estimated glomerular filtration rate (eGFR) values play an important role in determining medical urgency for LT. However, the use of sCr to assess kidney function may be limited in the cirrhotic milieu due to decreased creatinine production, interference of bilirubin with some laboratory assays for sCr, and expansion of the volume of distribution of creatinine. Therefore, conventional eGFR equations perform poorly in patients with cirrhosis and may overestimate kidney function leading to delayed diagnosis of acute kidney injury or lower priority for LT in patients with a truly low glomerular filtration rate. In this review, we will provide an update on the use of sCr for diagnosis and staging of kidney disease in patients with cirrhosis, discuss the limitations of sCr-based eGFR equations, and discuss novel eGFR equations that have been developed in patients with cirrhosis.
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Affiliation(s)
- Connor Griffin
- Division of Hepatology, Baylor University Medical Center, Dallas, TX
| | - Sumeet K Asrani
- Division of Hepatology, Baylor University Medical Center, Dallas, TX
| | - Kevin R Regner
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI.
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16
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Gonzalez SA, Farfan Ruiz AC, Ibrahim RM, Wadei HM. Essentials of Liver Transplantation in the Setting of Acute Kidney Injury and Chronic Kidney Disease. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:356-367. [PMID: 37657882 DOI: 10.1053/j.akdh.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 09/03/2023]
Abstract
Kidney dysfunction is common among liver transplant candidates with decompensated cirrhosis and has a major impact on pre- and post-liver transplant survival. Updated definitions of acute kidney injury and criteria for the diagnosis of hepatorenal syndrome allow for early recognition and intervention, including early initiation of vasoconstrictor therapy for hepatorenal syndrome. The rise of the metabolic syndrome and nonalcoholic fatty liver disease as a cause of cirrhosis has coincided with an increase in intrinsic chronic kidney disease recognized in transplant candidates and recipients. Ultimately, the ability to accurately assess kidney function and associated risk is essential to decision-making in the context of transplantation, including selection of candidates for simultaneous liver and kidney transplantation.
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Affiliation(s)
- Stevan A Gonzalez
- Division of Hepatology, Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White All Saints Medical Center Fort Worth and Baylor University Medical Center Dallas, TX; Department of Medicine, Burnett School of Medicine at TCU, Fort Worth, TX.
| | - Ana Cecilia Farfan Ruiz
- Division of Transplant Nephrology, Department of Transplant, Mayo Clinic College of Medicine and Science, Jacksonville, FL
| | - Ramez M Ibrahim
- Division of Transplant Nephrology, Department of Transplant, Mayo Clinic College of Medicine and Science, Jacksonville, FL
| | - Hani M Wadei
- Division of Transplant Nephrology, Department of Transplant, Mayo Clinic College of Medicine and Science, Jacksonville, FL
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17
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Stewart D, Mupfudze T, Klassen D. Does anybody really know what (the kidney median waiting) time is? Am J Transplant 2023; 23:223-231. [PMID: 36695688 DOI: 10.1016/j.ajt.2022.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/10/2022] [Accepted: 12/05/2022] [Indexed: 01/13/2023]
Abstract
The median waiting time (MWT) to deceased donor kidney transplant is of interest to patients, clinicians, and the media but remains elusive due to both methodological and philosophical challenges. We used Organ Procurement and Transplantation Network data from January 2003 to March 2022 to estimate MWTs using various methods and timescales, applied overall, by era, and by candidate demographics. After rising for a decade, the overall MWT fell to 5.19 years between 2015 and 2018 and declined again to 4.05 years (April 2021 to March 2022), based on the Kaplan-Meier method applied to period-prevalent cohorts. MWTs differed markedly by blood type, donor service area, and pediatric vs adult status, but to a lesser degree by race/ethnicity. Choice of methodology affected the magnitude of these differences. Instead of waiting years for an answer, reliable kidney MWT estimates can be obtained shortly after a policy is implemented using the period-prevalent Kaplan-Meier approach, a theoretical but useful construct for which we found no evidence of bias compared with using incident cohorts. We recommend this method be used complementary to the competing risks approach, under which MWT is often inestimable, to fill the present information void concerning the seemingly simple question of how long it takes to get a kidney transplant in the United States.
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Affiliation(s)
| | | | - David Klassen
- Office of the Chief Medical Officer, United Network for Organ Sharing
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18
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Engen RM, Kirmani S. Pediatric impacts of multiorgan transplant allocation policy in the United States. Pediatr Transplant 2023; 27 Suppl 1:e14253. [PMID: 36468327 DOI: 10.1111/petr.14253] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Multiorgan transplantation is increasingly common, driving recent increased attention to multiorgan allocation policies. METHODS In this review, we summarize current multiorgan transplant allocation policies in the United States, with attention to recent and proposed changes and their impact on pediatric candidates. RESULTS Existing multiorgan transplant policies attempt to balance equity and utility. Currently, there are clear allocation policies for some, but not all, multiorgan transplant combinations, and there are no mandatory outcomes reporting. Multiorgan candidates are prioritized above all kidney-alone transplant candidates, which negatively affect pediatric kidney transplant wait times. Pediatric candidates are typically exempt from multiorgan listing criteria. CONCLUSION Multiorgan transplant allocation presents unique challenges for policy development. As the United States Network for Organ Sharing begins exploring continuous distribution allocation, multiorgan allocation will require special consideration and the development of clear and equitable policies.
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Affiliation(s)
- Rachel M Engen
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Sonya Kirmani
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
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19
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Formica RN, Schold JD. The Unintended Consequences of Changes to the Organ Allocation Policy. J Am Soc Nephrol 2023; 34:14-16. [PMID: 36719146 PMCID: PMC10101628 DOI: 10.1681/asn.0000000000000009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
| | - Jesse D. Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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20
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Singal AK, Kuo YF, Reddy KR, Bataller R, Kwo P. Healthcare burden and outcomes of hepatorenal syndrome among cirrhosis-related hospitalisations in the US. Aliment Pharmacol Ther 2022; 56:1486-1496. [PMID: 36196562 DOI: 10.1111/apt.17232] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/07/2022] [Accepted: 09/11/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Hepatorenal syndrome (HRS) contributes to significant morbidity and mortality in hospitalised patients with cirrhosis. AIMS To examine recent trends, magnitude and outcomes of HRS in the National Inpatient Sample (NIS) database METHODS: Among the NIS database on cirrhosis hospitalisations (2016-2019) due to alcohol (ALD), chronic viral hepatitis (CVH), or NASH and complicated by acute kidney injury (AKI) were analyzed. RESULTS Of 113,454 hospitalisations, 18,735 (16.5%) had HRS (mean age 56 years, 36% females, 68% whites, 80% ALD, 7% NASH) with a stable trend over time. Among 1:1 propensity-matched 36,090 hospitalisations, the odds of HRS were 12% higher in NASH versus CVH. Based on weighted national estimates, there were 27,180 (8.3 per 100,000 US population) HRS hospitalisations in 2019, with economic burden of $4.2 billion USD. Mean hospitalisation and total charges (ALD vs. CVH vs. NASH) were 11 versus 10.8 versus 9.2 days and 151,000 versus 157,000 versus 120,000 USD, respectively; p < 0.001. In-hospital mortality was 18.9%, higher in HRS (25.8 vs. 12%, p < 0.001), and decreased by 15% annually. Survivors were more likely to be discharged to short- or long-term care facilities (HRS vs. non-HRS [42 vs. 27%, p < 0.001]); only 28.7% received palliative care. CONCLUSION HRS was the cause of AKI in 16.5% of patients hospitalised with cirrhosis and conferred significant healthcare burden with 27,180 HRS hospitalisations in 2019 and requiring an estimated 4.2 billion USD for hospital care. While there has been a decrease in in-hospital mortality over time, it remained high at 23.7% in 2019 in those with HRS.
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Affiliation(s)
- Ashwani K Singal
- Department of Medicine, University of SD Sanford School of Medicine, Sioux Falls, South Dakota, USA.,Division of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, South Dakota, USA
| | - Yong-Fang Kuo
- Department of Biostatistics, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramon Bataller
- Division of Gastroenterology and Hepatology, UPMC, Pittsburgh, Philadelphia, USA
| | - Paul Kwo
- Division of Gastroenterology and Hepatology, Stanford University Medical School, Stanford, California, USA
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21
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Ahsan SA, Guha A, Gonzalez J, Bhimaraj A. Combined Heart-Kidney Transplantation: Indications, Outcomes, and Controversies. Methodist Debakey Cardiovasc J 2022; 18:11-18. [PMID: 36132574 PMCID: PMC9461692 DOI: 10.14797/mdcvj.1139] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/08/2022] [Indexed: 11/21/2022] Open
Abstract
Renal dysfunction, a prevalent comorbidity in advanced heart failure, is associated with significant morbidity and mortality after heart transplantation. In the recent era, the field of combined heart-kidney transplantation has experienced great success in the treatment of both renal and cardiac dysfunction in end-stage disease states, and the number of transplants has increased dramatically. In this review, we discuss appropriate indications and selection criteria, overall and organ-specific outcomes, and future perspectives in the field of combined heart-kidney transplantation.
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Affiliation(s)
- Syed Adeel Ahsan
- Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas, US
| | - Ashrith Guha
- Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas, US
| | - Juan Gonzalez
- The Kidney Institute, Houston Methodist, Houston, Texas, US
| | - Arvind Bhimaraj
- Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas, US
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22
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Singal AK, Kuo YF, Kwo P, Mahmud N, Sharma P, Nadim MK. Impact of medical eligibility criteria and OPTN policy on simultaneous liver kidney allocation and utilization. Clin Transplant 2022; 36:e14700. [PMID: 35543138 PMCID: PMC9930183 DOI: 10.1111/ctr.14700] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/01/2022] [Accepted: 05/02/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Organ Procurement and Transplantation Network (OPTN) implemented medical eligibility and safety-net policy on 8/10/17 to optimize simultaneous liver-kidney (SLK) utilization. We examined impact of this policy on SLK listings and number of kidneys used within 1-yr. of receiving liver transplantation (LT) alone. METHODS AND RESULTS OPTN database (08/10/14-06/12/20) on adults (N = 66 709) without previous transplant stratified candidates to listings for SLK or LT alone with pre-LT renal dysfunction at listing (eGFR < 30 mL/min or on dialysis). Outcomes were compared for pre (08/10/14-08/09/17) vs. post (08/10/17-06/12/20) policy era. SLK listings decreased in post vs. pre policy era (8.7% vs. 9.6%; P < .001), with 22% reduced odds of SLK listing in the postpolicy era, with a decrease in all OPTN regions except regions 6 and 8, which showed an increase. Among LT-alone recipients with pre-LT renal dysfunction (N = 3272), cumulative 1-year probability was higher in post vs. prepolicy period for dialysis (5.6% vs. 2.3%; P < .0001), KT listing (11.4% vs. 2.0%; P < .0001), and KT (3.7% vs. .25%; P < .0001). Sixty-seven (2.4%) kidneys were saved in post policy era, with 18.1%, 16.6%, 4.3%, and 2.9% saving from regions 7, 2, 11, and 1, respectively. CONCLUSION Medical eligibility and safety-net OPTN policy resulted in decreased SLK use and improved access to LT alone among those with pre-LT renal dysfunction. Although decreased in postpolicy era, regional variation of SLK listings remains. In spite of increased use of KT within 1-year of receiving LT alone under safety net, less number of kidneys were used without impact on patient survival in postpolicy era.
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Affiliation(s)
- Ashwani K. Singal
- Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA,Avera McKennan University Hospital and Transplant Institute, Sioux Falls, South Dakota, USA
| | - Yong-Fang Kuo
- Department of Biostatistics and Preventive Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Paul Kwo
- Division of Gastroenterology and Hepatology, Stanford University Medical University, Stanford, California, USA
| | - Nadim Mahmud
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Mitra K. Nadim
- Division of Nephrology and Hypertension, University of Southern California, Los Angeles, California, USA
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23
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Asch WS. Is Prioritization of Kidney Allografts to Combined Liver-Kidney Recipients Appropriate? COMMENTARY. KIDNEY360 2022; 3:999-1002. [PMID: 35849645 PMCID: PMC9255872 DOI: 10.34067/kid.0005042021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/14/2021] [Indexed: 01/10/2023]
Affiliation(s)
- William S. Asch
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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24
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Pros and Cons of the Safety Net Rule for Prioritization of Liver Transplant Recipients Who Receive Liver Alone Transplant but Develop End-Stage Renal Disease. Clin Liver Dis 2022; 26:269-281. [PMID: 35487610 DOI: 10.1016/j.cld.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The number of patients presenting with cirrhosis with kidney injury and the potential need for SLKT is increasing. In 2017, standardized criteria were implemented to identify candidates for SLKT as well as criteria for prioritizing LTA recipients for kidney transplant if they developed kidney failure, which is referred to as the 'safety net rule.' Goal of the safety net rule is to provide a pathway that provides increased priority to LTA recipients with renal failure who may have previously undergone SLKT. This article reviews the pros and cons of the safety net rule for liver transplant recipients who develop ESRD.
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25
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Shaw BI, Samoylova ML, Barbas AS, Cheng XS, Lu Y, McElroy LM, Sanoff S. Center variations in patient selection for simultaneous heart-kidney transplantation. Clin Transplant 2022; 36:e14619. [PMID: 35175664 PMCID: PMC10067274 DOI: 10.1111/ctr.14619] [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: 10/20/2021] [Revised: 01/20/2022] [Accepted: 02/12/2022] [Indexed: 11/28/2022]
Abstract
There are no established regulations governing patient selection for simultaneous heart-kidney (SHK) transplantation, creating the potential for significant center-level variations in clinical practice. METHODS Using the United Network for Organ Sharing (UNOS) Standard Transplant Analysis and Research (STAR) file, we examined practice trends and variations in patient selection for SHK at the center level between January 1, 2004 and March 31, 2019. RESULTS Overall, SHK is becoming more common with most centers performing heart transplants also performing SHK. Among patients who underwent heart transplant who were receiving dialysis, the rate of SHK varied from 22% to 86% at the center level. Among patients not on dialysis, the median estimated glomerular filtration rate (eGFR) of patients receiving SHK varied between 19 and 59 mL/min/1.73 m2 . When adjusting for other factors, the odds of SHK varied 57-fold between the highest and lowest SHK performing centers. CONCLUSION Variation in SHK at the center level suggests the need for national guidelines around the selection of patients for SHK.
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Affiliation(s)
- Brian I Shaw
- Department of Surgery, Duke, University, Durham, North Carolina, USA
| | - Marya L Samoylova
- Department of Surgery, Duke, University, Durham, North Carolina, USA
| | - Andrew S Barbas
- Department of Surgery, Duke, University, Durham, North Carolina, USA
| | - Xingxing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University, Palo Alto, California, USA
| | - Yee Lu
- Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa M McElroy
- Department of Surgery, Duke, University, Durham, North Carolina, USA
| | - Scott Sanoff
- Department of Medicine, Division of Nephrology, Duke University, Durham, North Carolina, USA
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26
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Simultaneous Liver-Kidney Transplantation and the Use of Intraoperative Dialysis: A Monocenter Study. Transplant Proc 2022; 54:1002-1006. [DOI: 10.1016/j.transproceed.2022.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/18/2022] [Indexed: 11/19/2022]
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27
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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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28
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Asrani SK, Levitsky J. Mission accomplished? Early data from the simultaneous liver-kidney transplantation allocation policy. Am J Transplant 2021; 21:3513-3515. [PMID: 34375502 DOI: 10.1111/ajt.16796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 01/25/2023]
Affiliation(s)
| | - Josh Levitsky
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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