Outcomes of Simultaneous Liver/Kidney Transplants Are Equivalent to Kidney Transplant Alone: A Preliminary Report

Abstract

Background With adoption of Model for End-stage Liver Disease (MELD), 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 (1). Methods To investigate outcome of KTx in SLK, all SLK (n=36) performed at our center from 1/2000–12/2007 were reviewed and KTx outcomes compared to those of kidney transplant alone (KTA) performed during that period (n=1,283). We also reviewed whether pre-transplant panel reactive antibody (PRA) and donor specific antibody (DSA) affected KTx outcome in SLK. Results One- and three-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 to 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 three years compared to non-sensitized 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 to KTA regardless of level of preoperative PRA. A high level of DSA should not preclude simultaneous transplantation when clinically indicated.

Decreased chronic cellular and antibody-mediated injury in the kidney following simultaneous liver-kidney transplantation

“…4 Several singleinstitution analyses also confirmed a decreased incidence of acute rejection in SLK patients. [8][9][10] Our study extends these previous studies in that the surveillance biopsies allowed us to examine subclinical rejection and lower levels of inflammation that do not meet criteria for acute rejection by Banff classification, but may affect graft outcome. 11 These data demonstrate that SCI is more common in KTA.…”

An update on the impact of pre-transplant transfusions and allosensitization on time to renal transplant and on allograft survival

“…Most studies reported a detrimental effect of allosensitization on graft rejection: 9 studies reported a significant detrimental effect [13,14,39-45], and 7 studies reported a non-significant detrimental effect [12,15,16,46-49] (Figure 4). In contrast, 6 studies reported a non-detrimental effect of allosensitization on graft rejection [50-55].…”

Immunology of Transplant Protocols

“…In addition, simultaneous transplant of syngeneic solid organ transplants may diminish the immunogenicity of one or both of the grafts. This has been suggested to contribute to improved kidney survival in simultaneous liver-kidney transplant, especially in recipients who are sensitized to donor HLA antigens prior to transplant [37].…”