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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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2
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Yanagaki M, Haruki K, Furukawa K, Taniai T, Akaoka M, Shirai Y, Abe K, Onda S, Matsumoto M, Uwagawa T, Ikegami T. Liver Only Living Donor Transplantation for Polycystic Disease in a Patient on Chronic Hemodialysis: Case Report. Transplant Proc 2023:S0041-1345(23)00212-9. [PMID: 37100734 DOI: 10.1016/j.transproceed.2023.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/27/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Polycystic liver disease (PLD) is characterized by the progressive development of polycystic lesions in the kidney and the liver, possibly resulting in dual organ failure. We indicated living donor liver transplantation (LDLT) for a patient with end-stage liver and kidney disease (ELKD) due to PLD on uncomplicated chronic hemodialysis. CASE PRESENTATION A 63-year-old man with ELKD and uncontrolled massive ascites due to PLD and hepatitis B on uncomplicated chronic hemodialysis was referred to us with a single possible 47-year-old female living donor. Because of the necessity of right lobe liver procurement from this small middle-aged donor and uncomplicated hemodialysis on this recipient, we considered LDLT, rather than dual organ transplantation, could be the most well-balanced option to save the life of this recipient with acceptable risk limits for this donor. A right lobe graft with 0.91 for graft recipient weight ratio was implanted with an uneventful operative procedure under intra- and postoperative continuous hemodiafiltration. The recipient was rescheduled on routine hemodialysis on day 6 after transplantation and recovered with a gradual decrease in ascites output. He was discharged on day 56. He continues to have a very good liver function and quality of life without ascites and uncomplicated routine hemodialysis 1 year after transplantation. The living donor was discharged 3 weeks after surgery and is also doing well. CONCLUSION Although combined liver-kidney transplantation from a deceased donor could be the best option for ELKD due to PLD, LDLT can also be an acceptable option for ELKD with uncomplicated hemodialysis, considering the double equipoise theory for both lifesaving of the recipient and acceptable donor risk.
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Affiliation(s)
- Mitsuru Yanagaki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Koichiro Haruki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Tomohiko Taniai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Munetoshi Akaoka
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiro Shirai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kyohei Abe
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinji Onda
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Michinori Matsumoto
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Tadashi Uwagawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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3
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Analysis of Native Kidney Function Recovery With Renal Scintigraphy Following Simultaneous Liver-Kidney Transplantation. Transplantation 2023; 107:540-547. [PMID: 36228323 DOI: 10.1097/tp.0000000000004310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patients undergoing simultaneous liver-kidney transplantation (SLK) have impaired native kidney function. The relative contribution of allograft versus native function after SLK is unknown. We sought to characterize the return of native kidney function following SLK. METHODS Following SLK, patients underwent technetium-99 m-mercaptoacetyltriglycine renal scintigraphy following serum creatinine nadir. Kidney contributions to estimated glomerular filtration rate (eGFR) were determined. Patients with native kidney function at serum creatinine nadir contributing eGFR ≥30 versus <30 mL/min/1.73 m 2 were compared, and multiple linear regression analysis for native eGFR improvement was performed. RESULTS Thirty-one patients were included in this analysis. Average native kidney contribution to overall kidney function following SLK was 51.1% corresponding to native kidney eGFR of 44.5 mL/min/1.73 m 2 and native kidney function eGFR improvement of 30.3 mL/min/1.73 m 2 ( P < 0.001). Twenty-six of 31 patients had native kidney contribution of eGFR ≥30 mL/min/1.73 m 2 . Hepatorenal syndrome as the sole primary etiology of kidney dysfunction was 100% specific for native kidney eGFR >30 mL/min/1.73 m 2 and predicted native eGFR improvement ( P = 0.03). CONCLUSIONS Substantial improvement in native kidney function follows SLK, and hepatorenal syndrome as the sole primary etiology of kidney dysfunction is predictive of improvement. Whether such patients are suitable for liver transplant followed by surveillance with option for subsequent kidney transplants requires investigation.
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Fernández-Carrillo C, Li Y, Ventura-Cots M, Argemi J, Dai D, Clemente-Sánchez A, Duarte-Rojo A, Behari J, Ganesh S, Jonassaint NL, Tevar AD, Hughes CB, Humar A, Molinari M, Landsittel DP, Bataller R. Poor Outcomes of Patients With NAFLD and Moderate Renal Dysfunction or Short-Term Dialysis Receiving a Liver Transplant Alone. Transpl Int 2022; 35:10443. [PMID: 36568138 PMCID: PMC9784907 DOI: 10.3389/ti.2022.10443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 10/27/2022] [Indexed: 12/13/2022]
Abstract
The outcomes of patients with moderate renal impairment and the impact of liver disease etiology on renal function recovery after liver transplant alone (LTA) are largely unknown. We explored whether NAFLD patients with pre-LTA moderate renal dysfunction (GFR 25-45 ml/min/1.73 m2) may be more susceptible to develop post-LTA severe renal dysfunction (GFR<15 ml/min/1.73 m2) than ALD patients, as well as other overall outcomes. Using the UNOS/OPTN database, we selected patients undergoing liver transplant for NAFLD or ALD (2006-2016), 15,103 of whom received LTA. NAFLD patients with moderate renal dysfunction were more likely to develop subsequent GFR<15 ml/min/1.73 m2 than ALD patients (11.1% vs. 7.38%, p < 0.001). Patients on short-term dialysis pre-LTA (≤12 weeks) were more likely to develop severe renal dysfunction (31.7% vs. 18.1%), especially in NAFLD patients, and were more likely to receive a further kidney transplant (15.3% vs. 3.7%) and had lower survival (48.6% vs. 50.4%) after LTA (p < 0.001 for all). NAFLD was an independent risk factor for post-LTA severe renal dysfunction (HR = 1.2, p = 0.02). NAFLD patients with moderate renal dysfunction and those receiving short-term dialysis prior to LTA are at a higher risk of developing subsequent severe renal dysfunction. Underlying etiology of liver disease may play a role in predicting development and progression of renal failure in patients receiving LTA.
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Affiliation(s)
- Carlos Fernández-Carrillo
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,CIBERehd. Instituto de Salud Carlos III, Madrid, Spain,Gastroenterología y Hepatología, IDIPHISA, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Yaming Li
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Meritxell Ventura-Cots
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,CIBERehd. Instituto de Salud Carlos III, Madrid, Spain
| | - Josepmaria Argemi
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,CIBERehd. Instituto de Salud Carlos III, Madrid, Spain
| | - Dongling Dai
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Ana Clemente-Sánchez
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,CIBERehd. Instituto de Salud Carlos III, Madrid, Spain
| | - Andres Duarte-Rojo
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Jaideep Behari
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Swaytha Ganesh
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Naudia L. Jonassaint
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Amit D. Tevar
- Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Christopher B. Hughes
- Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Abhinav Humar
- Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Michele Molinari
- Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Douglas P. Landsittel
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ramon Bataller
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,*Correspondence: Ramon Bataller,
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5
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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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6
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Nair G, Nair V. Simultaneous Liver-Kidney Transplantation. Clin Liver Dis 2022; 26:313-322. [PMID: 35487613 DOI: 10.1016/j.cld.2022.01.011] [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
End-stage kidney disease (ESKD) after liver transplantation is associated with high morbidity and mortality. This increase in mortality can be offset by performing a kidney transplant at the time of the liver transplant in select cases. Accordingly, Margreiter and colleague; s performed the first simultaneous liver-kidney (SLK) transplant in 1983. The number of SLK transplants has increased by more than 300% since then. In 1990%, 1.7% of all liver transplants in the United States were SLK transplants which increased to 9.9% by 2016. This steep increase was likely due to the implementation of the model of end-stage liver disease (MELD) scoring system in 2002, which is heavily weighted by serum creatinine.
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Affiliation(s)
- Gayatri Nair
- Division of Kidney Disease and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, 400 Community Drive, Manhasset, NY 11030, USA
| | - Vinay Nair
- Division of Kidney Disease and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, 400 Community Drive, Manhasset, NY 11030, USA.
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7
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Buccheri S, Da BL. Hepatorenal Syndrome: Definitions, Diagnosis, and Management. Clin Liver Dis 2022; 26:181-201. [PMID: 35487604 DOI: 10.1016/j.cld.2022.01.002] [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
Hepatorenal syndrome (HRS) is a hemodynamically driven process mediated by renal dysregulation and inflammatory response. Albumin, antibiotics, and β-blockers are among therapies that have been studied in HRS prevention. There are no Food and Drug Administration-approved treatments for HRS although multiple liver societies have recommended terlipressin as first-line pharmacotherapy. Renal replacement therapy is the primary modality used to bridge to definitive therapy with orthotopic liver transplant or simultaneous liver-kidney transplant. Advances in our understanding of HRS pathophysiology and emerging therapeutic modalities are needed to change outcomes for this vulnerable population.
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Affiliation(s)
- Sebastiano Buccheri
- Department of Internal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, 400 Community Drive, Manhasset, NY 11030, USA
| | - Ben L Da
- Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases & Transplantation, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, 400 Community Drive, Manhasset, NY 11030, USA.
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8
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Lia D, Grodstein EI. Kidney Allocation Issues in Liver Transplantation Candidates with Chronic Kidney Disease and Severe Kidney Liver Injury. Clin Liver Dis 2022; 26:283-289. [PMID: 35487611 DOI: 10.1016/j.cld.2022.01.004] [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 liver transplant candidates with concomitant renal disease has been steadily rising since the implementation of MELD-based allocation in 2002. Consequently, the number of simultaneous liver-kidney (SLK) transplants being performed each year has also increased. However, the establishment of well-defined criteria for when to choose SLK over liver transplant alone has lagged behind. The lack of clear guidelines has worsened an already large shortage of transplantable kidneys. This article further explores the rationale for and outlines the implementation of the SLK allocation policy.
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Affiliation(s)
- Daniel Lia
- Transplant Surgery Fellowship, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 400 Community Drive, Manhasset, NY 11765, USA
| | - Elliot I Grodstein
- Transplant Surgery Fellowship, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 400 Community Drive, Manhasset, NY 11765, USA.
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9
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Nagai S, Suzuki Y, Kitajima T, Ivanics T, Shimada S, Kuno Y, Shamaa MT, Yeddula S, Samaniego M, Collins K, Rizzari M, Yoshida A, Abouljoud M. Paradigm Change in Liver Transplantation Practice After the Implementation of the Liver-Kidney Allocation Policy. Liver Transpl 2021; 27:1563-1576. [PMID: 34043869 DOI: 10.1002/lt.26107] [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: 02/10/2021] [Revised: 04/21/2021] [Accepted: 05/01/2021] [Indexed: 12/13/2022]
Abstract
The Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) policy regarding kidney allocation for liver transplantation (LT) patients was implemented in August 2017. This study evaluated the effects of the simultaneous liver-kidney transplantation (SLKT) policy on outcomes in LT alone (LTA) patients with kidney dysfunction. We analyzed adult primary LTA patients with kidney dysfunction at listing (estimated glomerular filtration rate [eGFR] less than 30 mL/minute or dialysis requirement) between January 2015 and March 2019 using the OPTN/UNOS registry. Waitlist practice and kidney transplantation (KT) listing after LTA were compared between prepolicy and postpolicy groups. There were 3821 LTA listings with eGFR <30 mL/minute included. The daily number of listings on dialysis was significantly higher in Era 2 (postpolicy group) than Era 1 (prepolicy group) (1.21/day versus 0.95/day; P < 0.001). Of these LTA listings, 90-day LT waitlist mortality, LTA probability, and 1-year post-LTA survival were similar between eras. LTA recipients in Era 2 had a higher probability for KT listing after LTA than those in Era 1 (6.2% versus 3.9%; odds ratio [OR], 3.30; P < 0.001), especially those on dialysis (8.4% versus 2.0%; OR, 4.38; P < 0.001). Under the safety net rule, there was a higher KT probability after LTA (26.7% and 53% at 6 months in Eras 1 and 2, respectively; P = 0.02). After the implementation of the policy, the number of LTA listings among patients on dialysis increased significantly. While their posttransplant survival did not change, KT listing after LTA increased. The safety net rule led to high KT probability and a low waitlist mortality rate in patients who were listed for KT after LTA. These results suggest that the policy successfully achieved the goals of providing appropriate opportunities of KT for LT patients, which did not compromise LTA waitlist or posttransplant outcomes in patients with kidney dysfunction and provided KT opportunities if patients developed kidney failure after LTA.
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Affiliation(s)
- Shunji Nagai
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Yukiko Suzuki
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Toshihiro Kitajima
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Tommy Ivanics
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Shingo Shimada
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Yasutaka Kuno
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Mhd Tayseer Shamaa
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Sirisha Yeddula
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | | | - Kelly Collins
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Michael Rizzari
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Atsushi Yoshida
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Marwan Abouljoud
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
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10
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Nilles KM, Levitsky J. Current and Evolving Indications for Simultaneous Liver Kidney Transplantation. Semin Liver Dis 2021; 41:308-320. [PMID: 34130337 DOI: 10.1055/s-0041-1729969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This review will discuss the etiologies of kidney disease in liver transplant candidates, provide a historical background of the prior evolution of simultaneous liver-kidney (SLK) transplant indications, discuss the current indications for SLK including Organ Procurement and Transplantation Network policies and Model for End Stage Liver Disease exception points, as well as provide an overview of the safety net kidney transplant policy. Finally, the authors explore unanswered questions and future research needed in SLK transplantation.
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Affiliation(s)
- Kathy M Nilles
- Division of Gastroenterology and Hepatology, Department of Medicine, MedStar Georgetown Transplant Institute, Georgetown University School of Medicine, Washington, District of Columbia
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Department of Medicine, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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11
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Biggins SW, Angeli P, Garcia-Tsao G, Ginès P, Ling SC, Nadim MK, Wong F, Kim WR. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 74:1014-1048. [PMID: 33942342 DOI: 10.1002/hep.31884] [Citation(s) in RCA: 300] [Impact Index Per Article: 100.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Scott W Biggins
- Division of Gastroenterology and Hepatology, and Center for Liver Investigation Fostering discovEryUniversity of WashingtonSeattleWA
| | - Paulo Angeli
- Unit of Hepatic Emergencies and Liver TransplantationDepartment of MedicineDIMEDUniversity of PadovaPaduaItaly
| | - Guadalupe Garcia-Tsao
- Department of Internal MedicineSection of Digestive DiseasesYale UniversityNew HavenCT.,VA-CT Healthcare SystemWest HavenCT
| | - Pere Ginès
- Liver Unit, Hospital Clinic, and Institut d'Investigacions Biomèdiques August Pi i SunyerUniversity of BarcelonaBarcelonaSpain.,Centro de Investigación Biomèdica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)MadridSpain
| | - Simon C Ling
- The Hospital for Sick Children, Division of Gastroenterology, Hepatology and Nutrition, and Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Mitra K Nadim
- Division of NephrologyUniversity of Southern CaliforniaLos AngelesCA
| | - Florence Wong
- Division of Gastroenterology and HepatologyUniversity Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - W Ray Kim
- Division of Gastroenterology and HepatologyStanford UniversityPalo AltoCA
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12
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Cannon RM, Goldberg DS, Eckhoff DE, Anderson DJ, Orandi BJ, Locke JE. Early Outcomes With the Liver-kidney Safety Net. Transplantation 2021; 105:1261-1272. [PMID: 33741848 DOI: 10.1097/tp.0000000000003365] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND A safety net policy was implemented in August 2017 giving liver transplant alone (LTA) recipients with significant renal dysfunction posttransplant priority for subsequent kidney transplantation (KT). This study was undertaken to evaluate early outcomes under this policy. METHODS Adults undergoing LTA after implementation of the safety net policy and were subsequently listed for KT between 60 and 365 days after liver transplantation contained in United Network for Organ Sharing data were examined. Outcomes of interest were receipt of a kidney transplant and postliver transplant survival. Safety net patients were compared with LTA recipients not subsequently listed for KT as well as to patients listed for simultaneous liver-kidney (SLK) transplant yet underwent LTA and were not subsequently listed for KT. RESULTS There were 100 patients listed for safety net KT versus 9458 patients undergoing LTA without subsequent KT listing. The cumulative incidence of KT following listing was 32.5% at 180 days. The safety net patients had similar 1-year unadjusted patient survival (96.4% versus 93.4%; P = 0.234) but superior adjusted survival (hazard ratio0.133, 0.3570.960; P = 0.041) versus LTA recipients not subsequently listed for KT. Safety net patients had superior 1-year unadjusted (96.4% versus 75.0%; P < 0.001) and adjusted (hazard ratio0.039, 0.1260.406; P < 0.001) survival versus SLK listed patients undergoing LTA without subsequent KT listing. CONCLUSIONS The safety net appears to provide rapid access to KT with good early survival for those able to take advantage of it. Survival of patients unable to qualify for KT listing after LTA needs to be better understood before further limitation of SLK, however.
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Affiliation(s)
- Robert M Cannon
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - David S Goldberg
- Division of Hepatology, Department of Medicine, University of Miami, Coral Gables, FL
| | - Devin E Eckhoff
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Douglas J Anderson
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Babak J Orandi
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E Locke
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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13
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Morelli MC, Rendina M, La Manna G, Alessandria C, Pasulo L, Lenci I, Bhoori S, Messa P, Biancone L, Gesualdo L, Russo FP, Petta S, Burra P. Position paper on liver and kidney diseases from the Italian Association for the Study of Liver (AISF), in collaboration with the Italian Society of Nephrology (SIN). Dig Liver Dis 2021; 53 Suppl 2:S49-S86. [PMID: 34074490 DOI: 10.1016/j.dld.2021.03.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/31/2021] [Accepted: 03/31/2021] [Indexed: 02/07/2023]
Abstract
Liver and kidney are strictly connected in a reciprocal manner, in both the physiological and pathological condition. The Italian Association for the Study of Liver, in collaboration with the Italian Society of Nephrology, with this position paper aims to provide an up-to-date overview on the principal relationships between these two important organs. A panel of well-recognized international expert hepatologists and nephrologists identified five relevant topics: 1) The diagnosis of kidney damage in patients with chronic liver disease; 2) Acute kidney injury in liver cirrhosis; 3) Association between chronic liver disease and chronic kidney disease; 4) Kidney damage according to different etiology of liver disease; 5) Polycystic kidney and liver disease. The discussion process started with a review of the literature relating to each of the five major topics and clinical questions and related statements were subsequently formulated. The quality of evidence and strength of recommendations were graded according to the GRADE system. The statements presented here highlight the importance of strong collaboration between hepatologists and nephrologists for the management of critically ill patients, such as those with combined liver and kidney impairment.
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Affiliation(s)
- Maria Cristina Morelli
- Internal Medicine Unit for the treatment of Severe Organ Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy, Via Albertoni 15, 40138, Bologna, Italy
| | - Maria Rendina
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Policlinic Hospital, Piazza G. Cesare 11, 70124, Bari, Italy
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Torino, Corso Bramante 88, 10126, Torino, Italy
| | - Luisa Pasulo
- Gastroenterology and Transplant Hepatology, "Papa Giovanni XXIII" Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Ilaria Lenci
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome Viale Oxford 81, 00133, Rome, Italy
| | - Sherrie Bhoori
- Hepatology and Hepato-Pancreatic-Biliary Surgery and Liver Transplantation, Fondazione IRCCS, Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133, Milan, Italy
| | - Piergiorgio Messa
- Unit of Nephrology, Università degli Studi di Milano, Via Commenda 15, 20122, Milano, Italy; Nephrology, Dialysis and Renal Transplant Unit-Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Commenda 15, 20122 Milano, Italy
| | - Luigi Biancone
- Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città Della Salute e della Scienza Hospital, University of Turin, Corso Bramante, 88-10126, Turin, Italy
| | - Loreto Gesualdo
- Nephrology Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, Università degli Studi di Bari "Aldo Moro", Piazza G. Cesare 11, 70124, Bari, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, PROMISE, University of Palermo, Piazza delle Cliniche, 2 90127, Palermo, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy.
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14
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Kim SB, Chang JW, Shin JH, Cho KS, Jung DH, Song GW, Ha TY, Moon DB, Kim KH, Ahn CS, Hwang S, Lee SG. Renal Recovery After Liver Transplantation Alone in Patients With Liver Cirrhosis and Severe Chronic Kidney Disease With Normal Kidney Size. Transplant Proc 2021; 53:1719-1725. [PMID: 33741203 DOI: 10.1016/j.transproceed.2021.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/21/2020] [Accepted: 01/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Most guidelines recommend simultaneous liver-kidney transplantation (SLKT) in patients with liver cirrhosis (LC) and severe chronic kidney disease (CKD) over liver transplantation alone (LTA). CKD, however, is not irreversible. This study evaluates the reversibility of kidney disease after LTA based on kidney size. MATERIALS AND METHODS In this single-center retrospective study, we classified 90 patients with LC and severe CKD into 3 groups: the normal kidney (NK)-LTA group (n=39), small kidney (SK)-LTA group (both kidneys <9 cm at the time of LTA, n=40), and SK-SLKT group (n=11). RESULTS The NK-LTA group had a lower percentage of hepatocellular carcinoma and a higher pre-liver transplantation (LT) estimated glomerular filtration rate. This group, however, was older, received livers from a higher percentage of deceased donors, and had a higher Child-Pugh score. Renal recovery, defined as the return of creatinine to their baseline, or a persistent change from baseline but not persistent (≥3 months) need for renal replacement therapy after LT, was found in 79% in the NK-LTA group, which was higher than 7.5% in the SK-LTA group. Renal and patient survival was found in 56% of the NK-LTA group, which was higher than 2.5% of the SK-LTA group. CONCLUSIONS There is a high percentage of renal recovery in the NK-LTA group, and accordingly, this does not justify SLKT, since this would result in a "waste" of kidneys. Therefore, KT after LT is recommended over SLKT for the LC patients with NK size.
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Affiliation(s)
- Soon Bae Kim
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jai Won Chang
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hoon Shin
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung Sik Cho
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Liver Transplantation and Hepato-Biliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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15
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Bari K, Sharma P. Optimizing the Selection of Patients for Simultaneous Liver-Kidney Transplant. Clin Liver Dis 2021; 25:89-102. [PMID: 33978585 DOI: 10.1016/j.cld.2020.08.006] [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] [Indexed: 01/31/2023]
Abstract
Simultaneous liver-kidney transplantation has increased significantly in the Model for End Stage Liver Disease era. The transplantation policy has evolved significantly since the implementation of allocation based on the Model for End Stage Liver Disease. Current policy takes into account the medical eligibility criteria for simultaneous liver-kidney transplantation listing. It also provides a safety net option and prioritizes kidney transplant after liver transplant recipients who are unlikely to recover their renal function within 60 to 365 days after liver transplant alone. This review seeks to understand the underlying challenges in carefully selecting the candidates while optimizing the patient selection.
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Affiliation(s)
- Khurram Bari
- Division of Gastroenterology and Hepatology, University of Cincinnati, 231 Albert Sabin Way, ML 0595, MSB 7259, Cincinnati, OH 45267, USA
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, 3912 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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16
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Wieliczko M, Ołdakowska-Jedynak U, Małyszko J. Clinical Relevance of Kidney Biopsy in Patients Qualified for Liver Transplantation and After This Procedure in the Model for End-stage Liver Disease (MELD) Era: Where Are We Today? Ann Transplant 2020; 25:e925891. [PMID: 33077702 PMCID: PMC7587156 DOI: 10.12659/aot.925891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/21/2020] [Indexed: 11/15/2022] Open
Abstract
Chronic kidney disease (CKD) has been recognized as an increasingly common complication of liver transplantation (OLTx). Post-transplant renal dysfunction contributes to long-term morbidity and mortality following OLTx and is a very important issue in the management of liver transplant recipients. Its etiology is multifactorial and can be determined by kidney biopsy, which is too rarely done in this patient group. In the clinical context of patients with liver cirrhosis, accurate and reliable evaluation of the renal injury is crucial. We performed a review of kidney biopsies in patients with symptoms of CKD (proteinuria/hematuria/elevated creatinine) before and after liver transplantation in the published literature. Kidney biopsies were performed either before or after liver transplantation using percutaneous technique. There are few reports on transjugular kidney biopsy. Biopsy results prevented unnecessary modification of immunosuppressive therapy or selection of candidates for liver transplantation. In our opinion, kidney biopsy is a clinically relevant diagnostic approach to recognize kidney disease before and after liver transplantation, it also helps with the management of kidney disease in this population, and it is safe. Kidney biopsy should be offered more often in liver transplant patients to ensure appropriate therapy in concomitant CKD in this population. Our decisions today will impact clinical outcomes in the future.
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17
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Abstract
To analyze the impact of acute-on-chronic liver failure (ACLF) immediately before liver transplantation (LT) on short-term kidney function.
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18
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Yazawa M, Cseprekal O, Helmick RA, Talwar M, Balaraman V, Podila PSB, Fossey S, Satapathy SK, Eason JD, Molnar MZ. Association between longer hospitalization and development of de novo donor specific antibodies in simultaneous liver-kidney transplant recipients. Ren Fail 2020; 42:40-47. [PMID: 31875761 PMCID: PMC6968335 DOI: 10.1080/0886022x.2019.1705338] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: De novo Donor Specific Antibodies (DSA) are considered as a risk factor for the kidney allograft outcomes in recipients after simultaneous liver-kidney transplantation (SLKT). We hypothesized that length of hospital stay (LOS) might be associated with de novo DSA development of due to the increased likelihood of receiving blood transfusions with reduced immunosuppressive regimens.Methods: This study is a single-center, retrospective cohort study consisting of 85 recipients who underwent SLKT from 2009 to 2018 in our hospital. We divided the patients into two groups according to LOS [long hospital stay (L) group (LOS >14 days) and short hospital stay (S) group (LOS ≤14 days)]. Propensity score (PS) has been created using logistic regression to predict LOS greater than median of 14 days. The association between the presence of de novo DSA and LOS was assessed by logistic regression models adjusted for PS.Results: The mean age at transplantation of the entire cohort was 55.5 ± 10.1 years. Sixty percent of the recipients were male and Caucasian. Median LOS in (L) group was three-fold longer than (S) group [L: median 30 days (IQR: 21-52), S: median 8.5 days (IQR: 7-11)]. Eight patients developed de novo DSA after SLKT (9.4%), all of them were in (L) group. Longer LOS was significantly associated with higher risk of development of de novo DSA in unadjusted (OR+ each 5 days: 1.09, 95% CI:1.02-1.16) and PS adjusted (OR+ each 5 days: 1.11, 95% CI:1.02-1.21) analysis.Conclusion: Longer hospitalization is significantly associated with the development of de novo DSA in SLKT.
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Affiliation(s)
- Masahiko Yazawa
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Orsolya Cseprekal
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Ryan A Helmick
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Manish Talwar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Vasanthi Balaraman
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Pradeep S B Podila
- Faith and Health Division, Methodist Le Bonheur Healthcare, Memphis, TN, USA.,Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, TN, USA
| | | | - Sanjaya K Satapathy
- Sandra Atlas Bass Center for Liver Diseases and Transplantation, Department of Medicine, Northshore University Hospital/Northwell Health, Manhasset, NY, USA
| | - James D Eason
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Miklos Z Molnar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary.,Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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19
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Racial/Ethnic Disparities in Access and Outcomes of Simultaneous Liver-Kidney Transplant Among Liver Transplant Candidates With Renal Dysfunction in the United States. Transplantation 2020; 103:1663-1674. [PMID: 30720678 DOI: 10.1097/tp.0000000000002574] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Since the Model for End-stage Liver Disease (MELD) allocation system was implemented, the proportion of simultaneous liver-kidney transplantation (SLKT) has increased significantly. However, whether racial/ethnic disparities exist in access to SLKT and post-SLKT survival remains understudied. METHODS A retrospective cohort of patients aged ≥18 years with renal dysfunction on the liver transplant (LT) waiting list was obtained from Organ Procurement and Transplantation Network. Renal dysfunction was defined as estimated glomerular filtration rate <60 mL/min/1.73 m at listing for LT. Multilevel time-to-competing-events regression adjusting for center effect was used to examine the likelihood of receiving SLKT. Inverse probability of treatment weighted survival analyses were used to analyze posttransplant mortality outcomes. RESULTS For patients with renal dysfunction at listing for LT, not listed for simultaneous kidney transplant, non-Hispanic black (NHB) and Hispanic patients were more likely to receive SLKT than non-Hispanic white (NHW) patients (NHB: multivariable-adjusted hazard ratio [aHR] 2.57; 95% confidence interval [CI], 1.42-4.65; Hispanic: aHR, 2.03; 95% CI, 1.14-3.60). For post-SLKT outcomes, compared to NHW patients, NHB patients had a lower mortality risk before 24 months (aHR, 0.80; 95% CI, 0.65-0.97) but had a higher mortality risk (aHR, 2.00; 95% CI, 1.59-2.55) afterward; in contrast, Hispanic patients had a lower overall mortality risk than NHW patients (aHR, 0.61; 95% CI, 0.51-0.74). CONCLUSIONS In the MELD era, racial/ethnic differences exist in access and survival of SLKT for patients with renal dysfunction at listing for LT. Future studies are warranted to examine whether these differences remain in the post-SLK allocation policy era.
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20
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Ekser B, Contreras AG, Andraus W, Taner T. Current status of combined liver-kidney transplantation. Int J Surg 2020; 82S:149-154. [PMID: 32084547 DOI: 10.1016/j.ijsu.2020.02.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 02/07/2020] [Indexed: 01/07/2023]
Abstract
Combined liver-kidney transplantation is a life-saving procedure for patients with end-stage liver disease and underlying chronic kidney disease, or prolonged acute kidney injury. Due to physiologic changes secondary to portal hypertension in patients with end-stage liver disease, kidney injury is common, and combined liver-kidney transplantation accounts for 10% of all the liver transplants performed in the United States. Recently implemented policy in the United States standardizes the medical criteria for eligibility, and introduces a 'safety net' for those who are transplanted with a liver graft alone, in order to be able to receive a kidney graft later. Increasing number of combined liver-kidney transplants provides a large cohort of patients to be studied in detail for identification of factors (both donor and recipient-related) associated with better outcomes. Data regarding the safety and efficacy of delaying the kidney transplant part of the combined liver-kidney transplantation, and the immunologic benefits of the multi-organ transplantations including the liver are emerging. Here, we review the most recent analyses, and provide our opinion regarding the best practices in combined liver-kidney transplantation based on the evidence.
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Affiliation(s)
- Burcin Ekser
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Alan G Contreras
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico.
| | - Wellington Andraus
- Digestive Organs Transplant Division, Gastroenterology Department, Sao Paulo University School of Medicine, Sao Paulo, Brazil.
| | - Timucin Taner
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN, USA; Department Immunology, Mayo Clinic, Rochester, MN, USA.
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21
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Liver Transplantation. THE CRITICALLY ILL CIRRHOTIC PATIENT 2020. [PMCID: PMC7122092 DOI: 10.1007/978-3-030-24490-3_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The field of liver transplantation has changed since the MELD scoring system became the most widely used donor allocation tool. Due to the MELD-based allocation system, sicker patients with higher MELD scores are being transplanted. Persistent organ donor shortages remain a challenging issue, and as a result, the wait-list mortality is a persistent problem for most of the regions. This chapter focuses on deceased donor and live donor liver transplantation in patients with complications of portal hypertension. Special attention will also be placed on donor-recipient matching, perioperative management of transplant patients, and the impact of hepatic hemodynamics on transplantation.
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22
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Zimmerman MA, Schiller J, Selim M, Kim J, Hong JC. Management of Renal Failure in the Liver Transplant Patient. CURRENT TRANSPLANTATION REPORTS 2019. [DOI: 10.1007/s40472-019-00259-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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23
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Is living donor liver transplantation justified in high model for end-stage liver disease candidates (35+)? Curr Opin Organ Transplant 2019; 24:637-643. [DOI: 10.1097/mot.0000000000000689] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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24
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News in pathophysiology, definition and classification of hepatorenal syndrome: A step beyond the International Club of Ascites (ICA) consensus document. J Hepatol 2019; 71:811-822. [PMID: 31302175 DOI: 10.1016/j.jhep.2019.07.002] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/13/2019] [Accepted: 07/04/2019] [Indexed: 12/12/2022]
Abstract
Renal dysfunction is a common, life-threatening complication occurring in patients with liver disease. Hepatorenal syndrome (HRS) has been defined as a purely "functional" type of renal failure that often occurs in patients with cirrhosis in the setting of marked abnormalities in arterial circulation, as well as overactivity of the endogenous vasoactive systems.4,5 In 2007, the International Club of Ascites (ICA) classified HRS into types 1 and 2 (HRS-1 and HRS-2).5 HRS-1 is characterised by a rapid deterioration of renal function that often occurs because of a precipitating event, while HRS-2 is a moderate and stable or slowly progressive renal dysfunction that often occurs without an obvious precipitant. Clinically, HRS-1 is characterised by acute renal failure while HRS-2 is mainly characterised by refractory ascites. Nevertheless, after these two entities were first described, new concepts, definitions, and diagnostic criteria have been developed by nephrologists for renal dysfunction in the general population and hospitalised patients. In particular, the definitions and characterisation of acute kidney injury (AKI), acute kidney disease and chronic kidney disease have been introduced/refined.6 Accordingly, a debate among hepatologists of the ICA led to a complete revision of the nomenclature and diagnosistic criteria for HRS-1, which was renamed HRS-AKI.7 Additionally, over recent years, greater granularity has been gained regarding the pathogenesis of HRS; it is now increasingly recognised that it is not a purely "functional" entity with haemodynamic derangements, but that systemic inflammation, oxidative stress and bile salt-related tubular damage may contribute significantly to its development. That is, HRS has an additional structural component that would not only make traditional diagnostic criteria less reliable, but would explain the lack of response to pharmacological treatment with vasoconstrictors plus albumin that correlates with a progressive increase in inflammation. Because classification, nomenclature, diagnostic criteria and pathogenic theories have evolved over the years since the traditional classification of HRS-1 and HRS-2 was first described, it was considered that all these novel aspects be reviewed and summarised in a position paper. The aim of this position paper authored by two hepatologists (members of ICA) and two nephrologists involved in the study of renal dysfunction in cirrhosis, is to complete the re-classification of HRS initiated by the ICA in 2012 and to provide an update on the definition, classification, diagnosis, pathophysiology and treatment of HRS.
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25
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Sharma P. Liver-Kidney: Indications, Patient Selection, and Allocation Policy. Clin Liver Dis (Hoboken) 2019; 13:165-169. [PMID: 31316763 PMCID: PMC6605734 DOI: 10.1002/cld.787] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 11/24/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Pratima Sharma
- Department of Gastroenterology and HepatologyUniversity of Michigan Institute of Healthcare Policy & InnovationAnn ArborMI
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26
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Cannon RM, Davis EG, Jones CM. A Tale of Two Kidneys: Differences in Graft Survival for Kidneys Allocated to Simultaneous Liver Kidney Transplant Compared with Contralateral Kidney from the Same Donor. J Am Coll Surg 2019; 229:7-17. [DOI: 10.1016/j.jamcollsurg.2019.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/28/2019] [Accepted: 04/15/2019] [Indexed: 12/21/2022]
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27
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Francoz C, Durand F, Kahn JA, Genyk YS, Nadim MK. Hepatorenal Syndrome. Clin J Am Soc Nephrol 2019; 14:774-781. [PMID: 30996046 PMCID: PMC6500947 DOI: 10.2215/cjn.12451018] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hepatorenal syndrome is a severe complication of end-stage cirrhosis characterized by increased splanchnic blood flow, hyperdynamic state, a state of decreased central volume, activation of vasoconstrictor systems, and extreme kidney vasoconstriction leading to decreased GFR. The contribution of systemic inflammation, a key feature of cirrhosis, in the development of hepatorenal syndrome has been highlighted in recent years. The mechanisms by which systemic inflammation precipitates kidney circulatory changes during hepatorenal syndrome need to be clarified. Early diagnosis is central in the management and recent changes in the definition of hepatorenal syndrome help identify patients at an earlier stage. Vasoconstrictive agents (terlipressin in particular) and albumin are the first-line treatment option. Several controlled studies proved that terlipressin is effective at reversing hepatorenal syndrome and may improve short-term survival. Not all patients are responders, and even in responders, early mortality rates are very high in the absence of liver transplantation. Liver transplantation is the only curative treatment of hepatorenal syndrome. In the long term, patients transplanted with hepatorenal syndrome tend to have lower GFR compared with patients without hepatorenal syndrome. Differentiating hepatorenal syndrome from acute tubular necrosis (ATN) is often a challenging yet important step because vasoconstrictors are not justified for the treatment of ATN. Hepatorenal syndrome and ATN may be considered as a continuum rather than distinct entities. Emerging biomarkers may help differentiate these two conditions and provide prognostic information on kidney recovery after liver transplantation, and potentially affect the decision for simultaneous liver-kidney transplantation.
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Affiliation(s)
- Claire Francoz
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France.,INSERM U1149, University Paris Diderot, Paris, France; and
| | - François Durand
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France.,INSERM U1149, University Paris Diderot, Paris, France; and
| | - Jeffrey A Kahn
- Division of Gastrointestinal and Liver Disease, Department of Medicine
| | - Yuri S Genyk
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, and
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
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Singal AK, Ong S, Satapathy SK, Kamath PS, Wiesner RH. Simultaneous liver kidney transplantation. Transpl Int 2019; 32:343-352. [DOI: 10.1111/tri.13388] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Ashwani K. Singal
- Division of Gastroenterology and Hepatology University of Alabama at Birmingham Birmingham AL USA
| | - Song Ong
- Division of Nephrology University of Alabama at Birmingham Birmingham AL USA
| | - Sanjaya K. Satapathy
- Division of Transplant Surgery Methodist Hospital Transplant Institute Memphis TN USA
| | - Patrick S. Kamath
- Division of Gastroenterology and Hepatology Mayo Clinic Rochester MN USA
| | - Russel H. Wiesner
- Division of Gastroenterology and Hepatology Mayo Clinic Rochester MN USA
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Molnar MZ, Joglekar K, Jiang Y, Cholankeril G, Abdul MKM, Kedia S, Gonzalez HC, Ahmed A, Singal A, Bhamidimarri KR, Aithal GP, Duseja A, Wong VWS, Gulnare A, Puri P, Nair S, Eason JD, Satapathy SK. Association of Pretransplant Renal Function With Liver Graft and Patient Survival After Liver Transplantation in Patients With Nonalcoholic Steatohepatitis. Liver Transpl 2019; 25:399-410. [PMID: 30369023 PMCID: PMC6709989 DOI: 10.1002/lt.25367] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 09/28/2018] [Indexed: 12/13/2022]
Abstract
Nonalcoholic steatohepatitis (NASH) is one of the top 3 indications for liver transplantation (LT) in Western countries. It is unknown whether renal dysfunction at the time of LT has any effect on post-LT outcomes in recipients with NASH. From the United Network for Organ Sharing-Standard Transplant Analysis and Research data set, we identified 4088 NASH recipients who received deceased donor LT. We divided our recipients a priori into 3 categories: group 1 with estimated glomerular filtration rate (eGFR) <30 mL/minute/1.73 m2 at the time of LT and/or received dialysis within 2 weeks preceding LT (n = 937); group 2 with recipients who had eGFR ≥30 mL/minute/1.73 m2 and who did not receive renal replacement therapy prior to LT (n = 2812); and group 3 with recipients who underwent simultaneous liver-kidney transplantation (n = 339). We examined the association of pretransplant renal dysfunction with death with a functioning graft, all-cause mortality, and graft loss using competing risk regression and Cox proportional hazards models. The mean ± standard deviation age of the cohort at baseline was 58 ± 8 years, 55% were male, 80% were Caucasian, and average exception Model for End-Stage Liver Disease score was 24 ± 9. The median follow-up period was 5 years (median, 1816 days; interquartile range, 1090-2723 days). Compared with group 1 recipients, group 2 recipients had 19% reduced trend for risk for death with a functioning graft (subhazard ratio [SHR], 0.81; 95% confidence interval [CI], 0.64-1.02) and similar risk for graft loss (SHR, 1.25; 95% CI, 0.59-2.62), whereas group 3 recipients had similar risk for death with a functioning graft (SHR, 1.23; 95% CI, 0.96-1.57) and graft loss (SHR, 0.18; 95% CI, 0.02-1.37) using an adjusted competing risk regression model. In conclusion, recipients with preserved renal function before LT showed a trend toward lower risk of death with a functioning graft compared with SLKT recipients and those with pretransplant severe renal dysfunction in patients with NASH.
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Affiliation(s)
- Miklos Z Molnar
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN.,Department of Medicine, University of Tennessee Health Science Center, Memphis, TN.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Kiran Joglekar
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Yu Jiang
- School of Public Health, University of Memphis, Memphis, TN
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA
| | | | - Satish Kedia
- School of Public Health, University of Memphis, Memphis, TN
| | - Humberto C Gonzalez
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA
| | - Ashwani Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | | | - Guruprasad Padur Aithal
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals National Health Service Trust and University of Nottingham, Nottingham, United Kingdom
| | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Agayeva Gulnare
- Department of Internal Medicine, Grand Hospital, Baku, Azerbaijan
| | - Puneet Puri
- Division of Gastroenterology, Hepatology and Nutrition, McGuire Veterans Affairs Medical Center, Virginia Commonwealth University, Richmond, VA
| | - Satheesh Nair
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - James D Eason
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Sanjaya K Satapathy
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
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30
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Pardo F, Pons JA, Castells L, Colmenero J, Gómez MÁ, Lladó L, Pérez B, Prieto M, Briceño J. VI consensus document by the Spanish Liver Transplantation Society. Cir Esp 2019; 96:326-341. [PMID: 29776591 DOI: 10.1016/j.ciresp.2017.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 11/19/2017] [Accepted: 12/13/2017] [Indexed: 12/20/2022]
Abstract
The goal of the Spanish Liver Transplantation Society (La Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, on October 20, 2016, the 6th Consensus Document Meeting was held, with the participation of experts from the 24 authorized Spanish liver transplantation programs. This Edition discusses the following subjects, whose summary is offered below: 1) limits of simultaneous liver-kidney transplantation; 2) limits of elective liver re-transplantation; and 3) liver transplantation after resection and hepatocellular carcinoma with factors for a poor prognosis. The consensus conclusions for each of these topics is provided below.
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Affiliation(s)
- Fernando Pardo
- Sociedad Española de Trasplante Hepático, Unidad de Trasplante Hepático, Clínica Universitaria de Navarra, Pamplona, España
| | - José Antonio Pons
- Sociedad Española de Trasplante Hepático, Unidad de Trasplante Hepático, Hospital Virgen de la Arrixaca, Murcia, España
| | - Lluís Castells
- Unidad de Trasplante Hepático, Hospital Vall d'Hebron, Barcelona, España
| | - Jordi Colmenero
- Unidad de Trasplante Hepático, Hospital Clínic, Barcelona, España
| | - Miguel Ángel Gómez
- Unidad de Trasplante Hepático, Hospital Virgen del Rocío, Sevilla, España
| | - Laura Lladó
- Unidad de Trasplante Hepático, Hospital de Bellvitge, Barcelona, España
| | - Baltasar Pérez
- Unidad de Trasplante Hepático, Hospital Universitario de Valladolid, Valladolid, España
| | - Martín Prieto
- Unidad de Trasplante Hepático, Hospital Universitario La Fe, Valencia, España
| | - Javier Briceño
- Comité Científico de la Sociedad Española de Trasplante Hepático, Unidad de Trasplante Hepático, Hospital Universitario Reina Sofía, Córdoba, España.
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Meraz-Muñoz A, García-Juárez I. Chronic kidney disease in liver transplantation: Evaluation of kidney function. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2019; 84:57-68. [PMID: 30612722 DOI: 10.1016/j.rgmx.2018.07.002] [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: 02/07/2018] [Revised: 06/06/2018] [Accepted: 07/02/2018] [Indexed: 11/18/2022]
Abstract
Chronic kidney disease is one of the main comorbidities affecting liver transplant recipients. Most of those patients have some degree of acute or chronic kidney dysfunction at the time of transplantation, moreover they can also develop de novo chronic kidney disease once transplanted. An important increase in the incidence of chronic kidney disease in the «MELD era» has been observed. This phenomenon has partially been attributed to the weight that kidney function carries for organ allocation. In addition, the generalized use of calcineurin inhibitors has also been a contributing factor. It is of the utmost importance for us to be familiar with the current methods for evaluating kidney function before and after a liver transplantation. The two main biomarkers available today for that purpose are serum creatinine and cystatin C. Several equations have been derived from those biomarkers and have been tested in that context with mixed results, due to their biologic variability and the lack of standardization in their measurement. The gold standard continues to be the direct determination of the glomerular filtration rate through different methods; however, that is only done for research purposes. It is also essential to know the current classification of acute kidney injury and chronic kidney disease in order to make early diagnosis. The present review focuses on the recognition, diagnosis, and classification of chronic kidney disease and acute kidney injury in liver transplantation recipients.
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Affiliation(s)
- A Meraz-Muñoz
- Medicina Interna y Nefrología, Centro Médico ABC, Ciudad de México, México
| | - I García-Juárez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
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Ning Q. Main Complications of AECHB and Severe Hepatitis B (Liver Failure). ACUTE EXACERBATION OF CHRONIC HEPATITIS B 2019. [PMCID: PMC7498917 DOI: 10.1007/978-94-024-1603-9_2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Qin Ning
- Department of Infectious Disease, Tongji Hospital, Wuhan, China
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Chronic kidney disease in liver transplantation: Evaluation of kidney function. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2019.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Cannon RM, Jones CM, Davis EG, Eckhoff DE. Effect of Renal Diagnosis on Survival in Simultaneous Liver-Kidney Transplantation. J Am Coll Surg 2018; 228:536-544.e3. [PMID: 30586642 DOI: 10.1016/j.jamcollsurg.2018.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Simultaneous liver-kidney transplantation is lifesaving, however, the utility of allocating 2 organs to a single recipient remains controversial, particularly in the face of potentially inferior survival. This study aims to determine the effect of renal indication for transplantation on simultaneous liver-kidney transplantation outcomes. METHODS All adult recipients of combined whole liver-kidney transplants in the United Network for Organ Sharing database from 2003 to 2016 with a renal diagnosis of hypertension (HTN), diabetes mellitus (DM), acute tubular necrosis (ATN), or hepatorenal syndrome (HRS) were examined. Comparisons were made between the HTN/DM group and the ATN/HRS group using standard statistical methods. RESULTS There were 1,204 patients in the HRS/ATN group vs 1,272 patients in the HTN/DM group. The HTN/DM patients were slightly older (58.1 vs 56.4 years; p < 0.001), more likely to have liver disease due to chronic viral hepatitis (33.2% vs 21.5%; p < 0.001), and less acutely ill (mean Model for End-Stage Liver Disease score of 27.2 vs 33.1; p < 0.001) than their HRS/ATN counterparts. The prevalence of nonalcoholic steatohepatitis was 16.8% in both groups. Donor demographics were similar in both groups, although HTN/DM patients were more likely to have a local (81.6% vs 67.7%; p < 0.001) rather than regional donor. Patient survival rates at 1, 3, and 5 years were significantly lower in the HTN/DM group (87.4%, 78.2%, and 71.2% vs 90.7%, 84.1%, and 76.6%, respectively). Median survival was 118 months for the HTN/DM group vs 139.7 months for the HRS/ATN (p < 0.001). The HTN/DM patients were at significantly higher risk of death (hazard ratio 1.533; p < 0.001), liver graft loss (hazard ratio 1.611; p < 0.001), and renal graft loss (hazard ratio 1.592; p < 0.001) than ATN/HRS patients on multivariable analysis. CONCLUSIONS Despite a lower acuity of illness, HTN/DM patients have inferior survival after simultaneous liver-kidney transplantation than those with ATN/HRS. This should be considered in risk adjustment and allocation schemes.
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Affiliation(s)
- Robert M Cannon
- Hiram C Polk Jr, MD Department of Surgery, Division of Transplantation, University of Louisville, Louisville, KY.
| | - Christopher M Jones
- Hiram C Polk Jr, MD Department of Surgery, Division of Transplantation, University of Louisville, Louisville, KY
| | - Eric G Davis
- Hiram C Polk Jr, MD Department of Surgery, Division of Transplantation, University of Louisville, Louisville, KY
| | - Devin E Eckhoff
- Department of Surgery, Division of Abdominal Transplantation, University of Alabama at Birmingham, Birmingham, AL
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Baseline and Center-Level Variation in Simultaneous Liver-Kidney Listing in the United States. Transplantation 2018; 102:609-615. [PMID: 29077659 DOI: 10.1097/tp.0000000000001984] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The Organ Procurement and Transplantation Network has implemented medical criteria to determine which candidates are most appropriate for simultaneous liver-kidney (SLK) transplantation in comparison to liver-alone transplantation. We investigated prepolicy center-level variation among SLK listing practice, in light of such criteria. METHODS We identified 4736 SLK-eligible candidates after Share-35 in the United States. We calculated the proportion of candidates at each center who were listed for SLK transplantation within 6 months of eligibility. Multilevel logistic regression and parametric survival model was used to estimate the center-specific probability of SLK listing, adjusting for patient and center-level characteristics. RESULTS Among 4736 SLK-eligible candidates, 64.8% were listed for SLK within 6 months of eligibility. However, the percentage of SLK listing ranged from 0% to 100% across centers. African American race, male sex, transplant history, diabetes, and hypertension were associated with a higher likelihood of SLK listing. Conversely, older age was associated with a lower likelihood of SLK listing. After adjusting for candidate characteristics, the percentage of SLK listing still ranged from 3.8% to 80.2% across centers; this wide variation persisted even after further adjusting for center-level characteristics. CONCLUSIONS There was significant prepolicy center-level variation in SLK listing for SLK-eligible candidates. Implementation of standardized SLK listing practices may reduce center-level variation and equalize access for SLK candidates across the United States.
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Hussain SM, Sureshkumar KK. Refining the Role of Simultaneous Liver Kidney Transplantation. J Clin Transl Hepatol 2018; 6:289-295. [PMID: 30271741 PMCID: PMC6160299 DOI: 10.14218/jcth.2017.00065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 02/05/2018] [Accepted: 03/22/2018] [Indexed: 12/14/2022] Open
Abstract
Adoption of the model for end-stage liver disease score by Organ Procurement and Transplant Network (OPTN) deceased donor liver allocation policy in 2002 has led to an increase in the number of simultaneous liver kidney (SLK) transplantation. Since kidney function recovery following liver transplantation is difficult to predict, allocation of the kidney for SLK transplantation thus far has not been based on much rationale and evidence. Lack of OPTN policy towards SLK organ allocation has resulted in great variations among transplant centers regarding SLK transplantation. Increasing use of kidneys towards SLK transplantation diverts deceased donor kidneys away from candidates awaiting kidney-alone transplantation. Recently OPTN/United Network of Organ Sharing has implemented medical eligibility criteria for adult SLK transplantation which also includes a concept of safety net. Implementation of the new policy is a move in a positive direction, providing consistency in our practice and evidence-based guidelines in selecting candidates for SLK transplantation. This policy needs to be monitored prospectively and modified based on new data that will emerge over time. This review outlines the literature on SLK transplantation and efforts towards developing rational policy on SLK organ allocation.
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Affiliation(s)
| | - Kalathil K. Sureshkumar
- *Correspondence to: Kalathil K. Sureshkumar, Division of Nephrology and Hypertension, Department of Medicine, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA. Tel: +1-412-359-3319, Fax: +1-412-359-4136, E-mail:
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Pardo F, Pons JA, Castells L, Colmenero J, Gómez MÁ, Lladó L, Pérez B, Prieto M, Briceño J. VI consensus document by the Spanish Liver Transplantation Society. GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 41:406-421. [PMID: 29866511 DOI: 10.1016/j.gastrohep.2018.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 02/19/2018] [Accepted: 05/14/2018] [Indexed: 12/13/2022]
Abstract
The goal of the Spanish Liver Transplantation Society (La Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, on October 20, 2016, the 6th Consensus Document Meeting was held, with the participation of experts from the 24 authorized Spanish liver transplantation programs. This Edition discusses the following subjects, whose summary is offered below: 1) limits of simultaneous liver-kidney transplantation; 2) limits of elective liver re-transplantation; and 3) liver transplantation after resection and hepatocellular carcinoma with factors for a poor prognosis. The consensus conclusions for each of these topics is provided below.
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Affiliation(s)
- Fernando Pardo
- Sociedad Española de Trasplante Hepático, Unidad de Trasplante Hepático, Clínica Universitaria de Navarra, Pamplona, España
| | - José Antonio Pons
- Sociedad Española de Trasplante Hepático, Unidad de Trasplante Hepático, Hospital Virgen de la Arrixaca, Murcia, España
| | - Lluís Castells
- Unidad de Trasplante Hepático, Hospital Vall d'Hebron, Barcelona, España
| | - Jordi Colmenero
- Unidad de Trasplante Hepático, Hospital Clínic, Barcelona, España
| | - Miguel Ángel Gómez
- Unidad de Trasplante Hepático, Hospital Virgen del Rocío, Sevilla, España
| | - Laura Lladó
- Unidad de Trasplante Hepático, Hospital de Bellvitge, Barcelona, España
| | - Baltasar Pérez
- Unidad de Trasplante Hepático, Hospital Universitario de Valladolid, Valladolid, España
| | - Martín Prieto
- Unidad de Trasplante Hepático, Hospital Universitario La Fe, Valencia, España
| | - Javier Briceño
- Comité Científico de la Sociedad Española de Trasplante Hepático, Unidad de Trasplante Hepático, Hospital Universitario Reina Sofía, Córdoba, España.
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Nagai S, Safwan M, Collins K, Schilke RE, Rizzari M, Moonka D, Brown K, Patel A, Yoshida A, Abouljoud M. Liver alone or simultaneous liver-kidney transplant? Pretransplant chronic kidney disease and post-transplant outcome - a retrospective study. Transpl Int 2018; 31:1028-1040. [PMID: 29722081 DOI: 10.1111/tri.13275] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/26/2018] [Accepted: 04/20/2018] [Indexed: 08/30/2023]
Abstract
The new Organ Procurement and Transplant Network/United Organ Sharing Network (OPTN/UNOS) simultaneous liver-kidney transplant (SLK) policy has been implemented. The aim of this study was to review liver transplant outcomes utilizing the new SLK policy. Liver transplant alone (LTA) and SLK patients between 2009 and 2015 were reviewed. Graft survival and post-transplant kidney function were investigated among LTA patients meeting the chronic kidney disease (CKD) criteria of the new policy (LTA-CKD group). To validate our findings, we reviewed and applied our analysis to the OPTN/UNOS registry. A total of 535 patients were eligible from our series. The LTA-CKD group (n = 27) showed worse 1-year graft survival, compared with the SLK group (n = 44), but not significant (81% vs. 93%, P = 0.15). The LTA-CKD group significantly increased a risk of post-transplant dialysis (odds ratio = 5.59 [95% CI = 1.27-24.7], P = 0.02 [Ref. normal kidney function]). Post-transplant dialysis was an independent risk factor for graft loss (hazard ratio = 7.25, 95% CI = 3.3-15.91, P < 0.001 [Ref. SLK]). In the validation analysis based on the OPTN/UNOS registry, the hazard of 1-year-graft loss in the LTA-CKD group (n = 751) was 34.8% higher than the SLK group (n = 2856) (hazard ratio = 1.348, 95% CI = 1.157-1.572, P < 0.001). Indicating SLK for patients who meet the CKD criteria may significantly improve transplant outcomes.
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Affiliation(s)
- Shunji Nagai
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Mohamed Safwan
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Kelly Collins
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Randolph E Schilke
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Michael Rizzari
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Dilip Moonka
- Gastroenterology, Henry Ford Hospital, Detroit, MI, USA
| | | | - Anita Patel
- Nephrology, Henry Ford Hospital, Detroit, MI, USA
| | - Atsushi Yoshida
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Marwan Abouljoud
- Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
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Aeder MI. Simultaneous Liver-Kidney Transplantation: Policy Update and the Challenges Ahead. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0190-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Quintero Bernabeu J, Juamperez J, Muñoz M, Rodriguez O, Vilalta R, Molino JA, Asensio M, Bilbao I, Ariceta G, Rodrigo C, Charco R. Successful long-term outcome of pediatric liver-kidney transplantation: a single-center study. Pediatr Nephrol 2018; 33:351-358. [PMID: 28842757 DOI: 10.1007/s00467-017-3782-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 07/04/2017] [Accepted: 08/02/2017] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Liver-kidney transplantation is a rare procedure in children, with just ten to 30 cases performed annually worldwide. The main indications are autosomal recessive polycystic liver-kidney disease and primary hyperoxaluria. This study aimed to report outcomes of liver-kidney transplantation in a cohort of pediatric patients. METHODS We retrospectively analyzed all pediatric liver-kidney transplantations performed in our center between September 2000 and August 2015. Patient data were obtained by reviewing inpatient and outpatient medical records and our transplant database. RESULTS A total of 14 liver-kidney transplants were performed during the study period, with a median patient age and weight at transplant of 144.4 months (131.0-147.7) and 27.3 kg (12.0-45.1), respectively. The indications for liver-kidney transplants were autosomal recessive polycystic liver-kidney disease (8/14), primary hyperoxaluria -1 (5/14), and idiopathic portal hypertension with end-stage renal disease (1/14). Median time on waiting list was 8.5 months (5.7-17.3). All but two liver-kidney transplants were performed simultaneously. Patients with primary hyperoxaluria-1 tended to present a delayed recovery of renal function compared with patients transplanted for other indications (62.5 vs 6.5 days, respectively, P 0.076). Patients with liver-kidney transplants tended to present a lower risk of acute kidney rejection than patients transplanted with an isolated kidney transplant (7.2% vs 32.7%, respectively; P < 0.07). Patient and graft survival at 1, 3, and 5 years were 100%, 91.7%, 91.7%, and 91.7%, 83.3%, 83.3%, respectively. No other grafts were lost. CONCLUSION Long-term results of liver-kidney transplants in children are encouraging, being comparable with those obtained in isolated liver transplantation.
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Affiliation(s)
- Jesús Quintero Bernabeu
- Pediatric Hepatology and Liver Transplant Unit, Hospital Universitari Vall d'Hebron, Universitat Atònoma de Barcelona, 08035, Barcelona, Spain.
| | - Javier Juamperez
- Pediatric Hepatology and Liver Transplant Unit, Hospital Universitari Vall d'Hebron, Universitat Atònoma de Barcelona, 08035, Barcelona, Spain
| | - Marina Muñoz
- Pediatric Nephrology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, 08035, Barcelona, Spain
| | - Olalla Rodriguez
- Pediatrics Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, 08035, Barcelona, Spain
| | - Ramon Vilalta
- Pediatric Nephrology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, 08035, Barcelona, Spain
| | - José A Molino
- Pediatric Surgery Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, 08035, Barcelona, Spain
| | - Marino Asensio
- Pediatric Surgery Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, 08035, Barcelona, Spain
| | - Itxarone Bilbao
- HPB Surgery and Transplants, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, 08035, Barcelona, Spain
| | - Gema Ariceta
- Pediatric Nephrology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, 08035, Barcelona, Spain
| | - Carlos Rodrigo
- Pediatrics Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, 08035, Barcelona, Spain
| | - Ramón Charco
- HPB Surgery and Transplants, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, 08035, Barcelona, Spain
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Modi RM, Tumin D, Kruger AJ, Beal EW, Hayes Jr D, Hanje J, Michaels AJ, Washburn K, Conteh LF, Black SM, Mumtaz K. Effect of transplant center volume on post-transplant survival in patients listed for simultaneous liver and kidney transplantation. World J Hepatol 2018; 10:134-141. [PMID: 29399287 PMCID: PMC5787677 DOI: 10.4254/wjh.v10.i1.134] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 12/01/2017] [Accepted: 12/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To examine the effect of center size on survival differences between simultaneous liver kidney transplantation (SLKT) and liver transplantation alone (LTA) in SLKT-listed patients.
METHODS The United Network of Organ Sharing database was queried for patients ≥ 18 years of age listed for SLKT between February 2002 and December 2015. Post-transplant survival was evaluated using stratified Cox regression with interaction between transplant type (LTA vs SLKT) and center volume.
RESULTS During the study period, 393 of 4580 patients (9%) listed for SLKT underwent a LTA. Overall mortality was higher among LTA recipients (180/393, 46%) than SLKT recipients (1107/4187, 26%). The Cox model predicted a significant survival disadvantage for patients receiving LTA vs SLKT [hazard ratio, hazard ratio (HR) = 2.85; 95%CI: 2.21, 3.66; P < 0.001] in centers performing 30 SLKT over the study period. This disadvantage was modestly attenuated as center SLKT volume increased, with a 3% reduction (HR = 0.97; 95%CI: 0.95, 0.99; P = 0.010) for every 10 SLKs performed.
CONCLUSION In conclusion, LTA is associated with increased mortality among patients listed for SLKT. This difference is modestly attenuated at more experienced centers and may explain inconsistencies between smaller-center and larger registry-wide studies comparing SLKT and LTA outcomes.
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Affiliation(s)
- Rohan M Modi
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, United States
| | - Andrew J Kruger
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Eliza W Beal
- Department of General Surgery, Division of Transplantation, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Don Hayes Jr
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Section of Pulmonary Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, United States
| | - James Hanje
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Anthony J Michaels
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Kenneth Washburn
- Department of General Surgery, Division of Transplantation, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Lanla F Conteh
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Sylvester M Black
- Department of General Surgery, Division of Transplantation, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Khalid Mumtaz
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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Simultaneous Liver-Kidney Transplantation: Impact on Liver Transplant Patients and the Kidney Transplant Waiting List. CURRENT TRANSPLANTATION REPORTS 2018; 5:1-6. [PMID: 29564203 PMCID: PMC5843696 DOI: 10.1007/s40472-018-0175-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose The number of simultaneous liver-kidney transplants (SLKT) performed in the USA has been rising. The Organ Procurement and Transplantation Network implemented a new policy governing SLKT that specifies eligibility criteria for candidates to receive a kidney with a liver, and creates a kidney waitlist “safety net” for liver recipients with persistent renal failure after transplant. This review explores potential impacts for liver patients and the kidney waitlist. Recent Findings Factors that have contributed to the rise in SLKT including Model for End-stage Liver Disease (MELD)-based allocation, regional sharing for high MELD candidates, and the rising incidence of non-alcoholic steatohepatitis will continue to increase the number of liver transplant candidates with concurrent renal insufficiency. The effect of center behavior based on the new policy is harder to predict, given wide historic variability in SLKT practice. Summary Continued increase in combined liver/kidney failure is likely, and SLKT and kidney after liver transplant may both increase. Impact of the new policy should be carefully monitored, but influences beyond the policy need to be accounted for.
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Allegretti AS, Parada XV, Eneanya ND, Gilligan H, Xu D, Zhao S, Dienstag JL, Chung RT, Thadhani RI. Prognosis of Patients with Cirrhosis and AKI Who Initiate RRT. Clin J Am Soc Nephrol 2018; 13:16-25. [PMID: 29122911 PMCID: PMC5753306 DOI: 10.2215/cjn.03610417] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 10/04/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Literature on the prognosis of patients with cirrhosis who require RRT for AKI is sparse and is confounded by liver transplant eligibility. An update on outcomes in the nonlisted subgroup is needed. Our objective was to compare outcomes in this group between those diagnosed with hepatorenal syndrome and acute tubular necrosis, stratifying by liver transplant listing status. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Retrospective cohort study of patients with cirrhosis acutely initiated on hemodialysis or continuous RRT at five hospitals, including one liver transplant center. Multivariable regression and survival analysis were performed. RESULTS Four hundred seventy-two subjects were analyzed (341 not listed and 131 listed for liver transplant). Among nonlisted subjects, 15% (51 of 341) were alive at 6 months after initiating RRT. Median survival was 21 (interquartile range [IQR], 8, 70) days for those diagnosed with hepatorenal syndrome and 12 (IQR, 3, 43) days for those diagnosed with acute tubular necrosis (P=0.25). Among listed subjects, 48% (63 of 131) received a liver transplant. Median transplant-free survival was 15 (IQR, 5, 37) days for those diagnosed with hepatorenal syndrome and 14 (IQR, 4, 31) days for those diagnosed with acute tubular necrosis (P=0.60). When stratified by transplant listing, with adjusted Cox models we did not detect a difference in the risk of death between hepatorenal syndrome and acute tubular necrosis (hazard ratio [HR], 0.81; 95% confidence interval [95% CI], 0.59 to 1.11, among those not listed; HR, 0.73; 95% CI, 0.44 to 1.19, among those listed). CONCLUSIONS Cause of AKI was not significantly associated with mortality in patients with cirrhosis who required RRT. Among those not listed for liver transplant, mortality rates were extremely high in patients both with hepatorenal syndrome and acute tubular necrosis. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_11_09_CJASNPodcast_18_1_A.mp3.
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Affiliation(s)
| | | | | | | | | | | | - Jules L. Dienstag
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Raymond T. Chung
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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MELD Stratified Outcomes Among Recipients With Diabetes or Hypertension: Simultaneous Liver Kidney Versus Liver Alone. J Clin Gastroenterol 2018; 52:67-72. [PMID: 28906426 DOI: 10.1097/mcg.0000000000000818] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIM Data are scanty on allocating simultaneous liver kidney (SLK) based on model for end-stage disease (MELD) score. Diabetes mellitus (DM) and hypertension (HTN) are frequent in cirrhosis patients. We analyzed transplant recipients with DM and/or HTN to compare MELD-based outcomes of SLK to liver transplantation alone (LTA). MATERIALS AND METHODS Of 13,584 first deceased donor liver transplantation among patients with DM and/or HTN (1530 or 11.2% SLK), MELD score predicted SLK [1.02 (1.01-1.03)]. SLK was beneficial for 5-year patient survival at MELD score ≥43 (78.6% vs. 62.6%, P=0.017), but not at MELD score <29 (74.8% vs. 76.2%, P=0.63). Among 11,405 recipients (976 SLK) at MELD score <29, SLK (n=816) was beneficial compared with 706 LTA [75% vs. 64%, P<0.001; 0.71 (0.55-0.91)] at serum creatinine (SC) ≥2 but not at SC<2 [73% vs. 76%, P=0.32; 0.85 (0.60-1.2)]. Among patients with MELD score 29 to 42, SLK (n=484) and LTA (n=1403) had similar survival [69% vs. 69%, P=0.58; 0.9 (0.7-1.5)]. Among patients with MELD score ≥43, SLK (n=70) was associated with 35% improved patient survival at 5 years compared with 222 LTA [0.65 (0.46-0.93)]. CONCLUSIONS Among patients with DM and/or HTN, SLK is useful at: (a) MELD score <29 and SC≥2 and (b) MELD score ≥43. Prospective studies are needed to confirm these findings as basis to optimize use of SLK.
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Tedesco D, Grakoui A. Environmental peer pressure: CD4 + T cell help in tolerance and transplantation. Liver Transpl 2018; 24:89-97. [PMID: 28926189 PMCID: PMC5739992 DOI: 10.1002/lt.24873] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/30/2017] [Accepted: 09/12/2017] [Indexed: 12/20/2022]
Abstract
The liver participates in a multitude of metabolic functions that are critical for sustaining human life. Despite constant encounters with antigenic-rich intestinal blood, oxidative stress, and metabolic intermediates, there is no appreciable immune response. Interestingly, patients undergoing orthotopic liver transplantation benefit from a high rate of graft acceptance in comparison to other solid organ transplant recipients. In fact, cotransplantation of a donor liver in tandem with a rejection-prone graft increases the likelihood of graft acceptance. A variety of players may account for this phenomenon including the interaction of intrahepatic antigen-presenting cells with CD4+ T cells and the preferential induction of forkhead box P3 (Foxp3) expression on CD4+ T cells following injurious stimuli. Ineffective insult management can cause chronic liver disease, which manifests systemically as the following: antibody-mediated disorders, ineffective antiviral and antibacterial immunity, and gastrointestinal disorders. These sequelae sharing the requirement of CD4+ T cell help to coordinate aberrant immune responses. In this review, we will focus on CD4+ T cell help due to the shared requirements in hepatic tolerance and coordination of extrahepatic immune responses. Overall, intrahepatic deviations from steady state can have deleterious systemic immune outcomes and highlight the liver's remarkable capacity to maintain a balance between tolerance and inflammatory response while simultaneously being inundated with a panoply of antigenic stimuli. Liver Transplantation 24 89-97 2018 AASLD.
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Affiliation(s)
- Dana Tedesco
- Emory Vaccine Center, Division of Microbiology and Immunology, Emory University
| | - Arash Grakoui
- Emory Vaccine Center, Division of Microbiology and Immunology, Emory University,Division of Infectious Disease, Emory University School of Medicine, Atlanta, GA,Corresponding Author: Arash Grakoui, Division of Infectious diseases, Emory Vaccine Center, Division of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA 30322, Telephone: (404) 727-9368;
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Feng S. Living donor liver transplantation in high Model for End-Stage Liver Disease score patients. Liver Transpl 2017; 23:S9-S21. [PMID: 28719072 DOI: 10.1002/lt.24819] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 06/28/2017] [Indexed: 01/02/2023]
Affiliation(s)
- Sandy Feng
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco, San Francisco, CA
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Outcomes of Highly Sensitized Patients Undergoing Simultaneous Liver and Kidney Transplantation: A Single-Center Experience With Desensitization. Transplant Proc 2017; 49:1394-1401. [DOI: 10.1016/j.transproceed.2017.01.079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 01/24/2017] [Indexed: 01/24/2023]
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Predictors of renal function recovery among patients undergoing renal replacement therapy following orthotopic liver transplantation. PLoS One 2017; 12:e0178229. [PMID: 28574999 PMCID: PMC5456041 DOI: 10.1371/journal.pone.0178229] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 05/10/2017] [Indexed: 12/26/2022] Open
Abstract
Renal dysfunction frequently occurs during the periods preceding and following orthotopic liver transplantation (OLT), and in many cases, renal replacement therapy (RRT) is required. Information regarding the duration of RRT and the rate of kidney function recovery after OLT is crucial for transplant program management. We evaluated a sample of 155 stable patients undergoing post-intensive care hemodialysis (HD) from a patient population of 908 adults who underwent OLT. We investigated the average time to renal function recovery (duration of RRT required) and determined the risk factors for remaining on dialysis > 90 days after OLT. Log-rank tests were used for univariate analysis, and Cox proportional hazards models were used to identify factors associated with the risk of remaining on HD. The results of our analysis showed that of the 155 patients, 28% had pre-OLT diabetes mellitus, 21% had pre-OLT hypertension, and 40% had viral hepatitis. Among the patients, the median MELD (Model for End-Stage Liver Disease) score was 27 (interquartile range [IQR] 22-35). When they were listed for liver transplantation, 32% of the patients had serum creatinine (Scr) levels > 1.5 mg/dL or were on HD, and 50% had serum creatinine (Scr) levels > 1.5 mg/dL or were on HD at the time of OLT. Of the transplanted patients, 25% underwent pre-OLT intermittent HD, and 14% and 41% underwent continuous renal replacement therapy (CRRT) pre-OLT and post-OLT, respectively. At 90 days post-OLT, 118 (76%) patients had been taken off dialysis, and 16 (10%) patients had died while undergoing HD. The median recovery time of these post-OLT patients was 33 (IQR 27–39) days. In the multivariate analysis, fulminant hepatic failure as the cause of liver disease (p<0.001), the absence of pre-OLT hypertension (p = 0.016), a lower intraoperative fresh-frozen plasma (FFP) transfusion volume (p = 0.019) and not undergoing pre-OLT intermittent HD (p = 0.032) were associated with performing RRT for less than 90 days. Therefore, a high proportion of OLT patients showed improved renal function after OLT, and those who were diagnosed with fulminant hepatic failure, had no pre-OLT hypertension, received a lower transfused volume of intraoperative FFP and did not undergo pre-OLT intermittent HD had a higher probability of recovery.
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Habib S, Khan K, Hsu CH, Meister E, Rana A, Boyer T. Differential Simultaneous Liver and Kidney Transplant Benefit Based on Severity of Liver Damage at the Time of Transplantation. Gastroenterology Res 2017; 10:106-115. [PMID: 28496531 PMCID: PMC5412543 DOI: 10.14740/gr803w] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2017] [Indexed: 12/14/2022] Open
Abstract
Background We evaluated the concept of whether liver failure patients with a superimposed kidney injury receiving a simultaneous liver and kidney transplant (SLKT) have similar outcomes compared to patients with liver failure without a kidney injury receiving a liver transplantation (LT) alone. Methods Using data from the United Network of Organ Sharing (UNOS) database, patients were divided into five groups based on pre-transplant model for end-stage liver disease (MELD) scores and categorized as not having (serum creatinine (sCr) ≤ 1.5 mg/dL) or having (sCr > 1.5 mg/dL) renal dysfunction. Of 30,958 patients undergoing LT, 14,679 (47.5%) had renal dysfunction, and of those, 5,084 (16.4%) had dialysis. Results Survival in those (liver failure with renal dysfunction) receiving SLKT was significantly worse (P < 0.001) as compared to those with sCr < 1.5 mg/dL (liver failure only). The highest mortality rate observed was 21% in the 36+ MELD group with renal dysfunction with or without SLKT. In high MELD recipients (MELD > 30) with renal dysfunction, presence of renal dysfunction affects the outcome and SLKT does not improve survival. In low MELD recipients (16 - 20), presence of renal dysfunction at the time of transplantation does affect post-transplant survival, but survival is improved with SLKT. Conclusions SLKT improved 1-year survival only in low MELD (16 - 20) recipients but not in other groups. Performance of SLKT should be limited to patients where a benefit in survival and post-transplant outcomes can be demonstrated.
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Affiliation(s)
- Shahid Habib
- Liver Institute, PLLC, 2830 North Swan Road, Suite 180, Tucson, AZ 85712, USA
| | - Khalid Khan
- Transplant Institute, MedStar Georgetown University Hospital, 3800 Reservoir Rd, Main, Washington, DC 20007, USA
| | - Chiu-Hsieh Hsu
- Division of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ 85742, USA
| | - Edward Meister
- Department of Medicine and Surgery, Divisions of Gastroenterology, Hepatology and Liver Transplantation, Liver Research Institute, College of Medicine, University of Arizona, Tucson, AZ 85742, USA.,Deceased (biostatistician)
| | - Abbas Rana
- Department of Surgery, Division of Transplantation, Baylor College of Medicine, Houston, TX 77030, USA
| | - Thomas Boyer
- Department of Medicine and Surgery, Divisions of Gastroenterology, Hepatology and Liver Transplantation, Liver Research Institute, College of Medicine, University of Arizona, Tucson, AZ 85742, USA
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