Nephrological Indications in Combined Liver-Kidney Transplantation

Renal transplant in patients with polycystic disease: the Italian experience

We analyzed the results of kidney transplantation in autosomal dominent polycystic kidney disease (ADPKD) patients in Italy, including 14,305 transplantations performed from January 2002 to December 2010, including: 12,859 first single or double kidneys from cadaveric donors (13% polycystic), 172 combined liver-kidney cases (22% polycystic), and 1,303 living-donor organs (7% polycystic). Among the first transplantations (12,008 single, 851 double), with follow-ups ranging from 16 to 120 months, polycystic patients demonstrated better graft survival compared with other kidney diseases (86% vs 82% at 5 years; P < .01); mortality was not different (92% vs 79% at 1 year). A better trend was obtained also among combined liver-kidney transplantations in ADPKD. Regarding pretransplantation management of polycystic patients, we noticed a conservative attitude in 32/35 transplant centers. The main indication for nephrectomy was for the lack of abdominal space. Regarding instrumental studies, 86% of centers asked for second-level investigations computerized tomography for kidney dimensions. Radiologic investigations for vasculocerebral malformations were required in 97% of the centers: 74% as a routine and 23% in the presence of familial history of cerebral hemorrhage. Polycystic patients are good candidates for kidney transplantation with correct management before transplantation.

Native kidney function after renal transplantation combined with other solid organs in preemptive patients

Kidney transplantations combined with other solid organs are progressively increasing in number. There are no guidelines regarding the nephrologic indications for combined transplantations, namely liver-kidney (LKT), or heart-kidney (HKT), in preemptive patients with chronic kidney failure who are not on regular dialysis therapy. The objective of this study was to assess the functional contribution of the native kidneys after preemptive kidney transplantation combined with other solid organs. From 2004, 9 patients (aged 50.3 +/- 8.5 years) with chronic kidney failure (creatinine 2.5 +/- 1.0 mg/dL) caused by polycystic kidney disease (n = 4), vascular nephropathy (n = 2), interstitial nephropathy (n = 1), glomerulonephritis (n = 1), or end-stage kidney disease (n = 1), underwent combined transplantations (8 LKT, 1 HKT). A scintigraphic functional study (Tc-99DMSA or Tc-99mMAG3), was performed at 4 +/- 3 months after transplantation to evaluate the functional contribution of both the native kidneys and the graft. All patients were given immunosuppressive drugs, including a calcineurin inhibitor (tacrolimus/or cyclosporine). At the time of scintigraphy, renal function in all patients was 1.3 +/- 0.3 mg/dL. The functional contribution of the transplanted kidneys was on average 77 +/- 18%. Only in 1 patient was the contribution of the graft <50%. At follow-up after 36 months, patient and kidney survivals were 100%. The study confirmed a high risk of loss of native kidney function in the presence of organic nephropathy. In light of our experience, a creatinine clearance <30 mL/min in an appropriate cutoff for a combined transplantation. Close clinical and instrumental assessment pretransplant is essential before proceeding with a combined transplant program to exclude functional forms and to optimize the use of organs.

Outcomes of simultaneous liver/kidney transplants are equivalent to kidney transplant alone: a preliminary report

BACKGROUND

With adoption of Model for End-Stage Liver Disease, the number of simultaneous liver-kidney transplants (SLK) has greatly increased. A recent registry study questioned the equity of allocating kidney transplants (KTx) simultaneously with liver transplantation due to poor outcomes (Locke et al., Transplantation 2008; 85: 935).

METHODS

To investigate outcome of KTx in SLK, all SLK (n=36) performed at our center from January 2000 to December 2007 were reviewed and KTx outcomes compared with those of kidney transplant alone (KTA) performed during that period (n=1283). We also reviewed whether pretransplant panel reactive antibody and donor-specific antibody affected KTx outcome in SLK.

RESULTS

One- and 3-year KTx and patient survival were not different between KTA and SLK regardless of sensitization level. There were 348 (27%) KTx failures in KTA vs. 6 (17%) in SLK (NS). Overall freedom from acute cellular rejection (ACR) and antibody-mediated rejection (AMR) in SLK was 93 and 96% at 3 years, compared with 72 and 78% in KTA (P=0.0105 and P=0.0744, respectively). Sensitized KTx recipients had more ACR and AMR (32 and 38%) at 3 years compared with nonsensitized recipients (28 and 20%) (P=0.23 and 0.0001, respectively). No differences in ACR and AMR were observed when SLK was divided and level of sensitization compared (P=0.17 and 0.65, respectively).

CONCLUSION

SLK is a life-saving procedure with excellent patient and graft survival. AMR incidence in the KTx appears reduced in SLK compared with KTA regardless of level of preoperative panel reactive antibody. A high level of donor-specific antibody should not preclude simultaneous transplantation when clinically indicated.

Combined liver-kidney transplantation in children: indications and outcome

Although it remains a relatively infrequent procedure in children, CLKT has become a viable option for a select group of pediatric patients with severe liver and kidney disease. Most are performed for rare primary diseases such as PH1, but a selected few are performed in the setting of concomitant hepatic and renal failure of uncertain etiology and prognosis. This article reviews the indications for and outcomes following CLKT in children. While it focuses on the specific primary diseases which impact liver and kidney function simultaneously, it addresses the indications based on concomitant hepatic and renal failure, such as seen in the hepatorenal syndrome, as well.

[Renal graft outcome in patients with associated liver transplant]

INTRODUCTION

Nearly 50% of liver transplant recipients have some degree of renal failure; patients in haemodialysis treatment have a higher risk of suffering hepatic diseases related to viral infections or concomitant pathologies. Improvement in surgical and organ preservation techniques and immunosuppressive therapy has permitted multiorganic transplants in patients needing both liver and kidney organs.

OBJECTIVES

To review our results in renal transplants in those patients with liver and kidney transplants.

MATERIAL AND METHOD

Retrospective study of the 15 patients with liver and kidney transplants performed in our Hospital. We have reviewed patients main characteristics, liver and renal failure causes, renal graft and patient outcome and complications relate to renal transplant.

RESULTS

Between 1975 and December 2006 we performed 1483 kidney transplants and between 1991 and December 2006, 409 liver transplants. We performed multiorganic liver and kidney transplants to 15 patients (4 women and 11 men). The average for liver transplant recipients was 52.5+/-9.3 years (range 37-61) and for kidney transplant recipients was 51+/-12.5 years (35-66). Cold ischemia was 6.4+/-5.4 hours (6-8) in simultaneous liver-kidney transplant and 20.5+/-5.4 (8-27 hours) in non-simultaneous ones. Three patients had a renal transplant before the liver one (two functioning which had no changes after hepatic transplant but the other was lost due to IgA glomeruloneprhitis relapse and received a simultaneous kidney-liver transplant). Six patients received a simultaneous kidney-liver transplant and eight patients a renal transplant between 16 and 83 months (x=50.5+/-25.9 months) after the liver transplant. A renal graft was lost due to renal vein thrombosis and two due to IgA relapse; the others were functioning between 6 and 264 months of follow-up (x=92.5+/-66.7) with creatinine levels of 1.86+/-mg/100, (range 1-4.5). Four patients died due to hepatic failure between 8 months and 21 years after renal transplant and another died of oesophagus cancer 14 years after the kidney transplant, in all cases with functioning renal graft. There were no cases of kidney graft acute rejection in simultaneous transplants but there were five in non-simultaneous ones. Immunotherapy was based on steroids and tacrolimus.

CONCLUSIONS

Liver-kidney transplants are worthy options in patients with hepatic and renal end failure. Acute rejection seems to have fewer incidences in simultaneous liver-kidney transplantation.