Results of combined and sequential liver-kidney transplantation

Becker, Thomas; Nyibata, Miguel; Lueck, Rainer; Bektaş, H.; Demirci, G.; Lehner, Frank; Tusch, GÃ1⁄4nter; Strassburg, Christian P.; Schwarz, Anke; Klempnauer, J.; Nashan, Bjoern

doi:10.1053/jlts.2003.50210

Cited by 58 publications

(18 citation statements)

References 49 publications

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“…There are therefore three groups of patients who need to be considered for this discussion: 1) patients with liver failure and renal failure secondary to hepatorenal syndrome; 2) patients with liver failure and renal failure secondary to intrinsic renal disease not yet on dialysis; and 3) patients with liver failure and renal failure secondary to intrinsic renal disease on dialysis. Each of these groups must be considered separately, not only from the standpoint of patient and graft survival benefit, but also from an immunologic standpoint, as sequential renal transplantation following liver transplantation has been shown to have worse outcomes vs. SLK (10–11). Our data supports the idea that SLK can be performed with equivalent graft and patient outcomes regardless of the level of preoperative sensitization.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2010

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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.

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Section: Discussionmentioning

confidence: 99%

“…Few would argue with this approach, as these patients would be placed on the renal waiting list regardless of their liver disease. Moreover, there are fewer immunologic concerns in SLK than if one were to receive an LTA with sequential KTA (10). …”

Section: Discussionmentioning

confidence: 99%

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

et al. 2010

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“…Since the introduction of the one-step SLK technique in the Institute for Clinical and Experimental Medicine (IKEM) in Prague (08/2013) and the University Hospitals Leuven (UZL) in Belgium (11/2013), all SLK for polycystic disease have been performed by the one-step approach. Although the use of a midline laparotomy in SLK has anecdotally been mentioned in the literature[7–9], the technique has never been described in detail nor has it been compared to the classical two-step approach.…”

Section: Introductionmentioning

confidence: 99%

Simultaneous liver kidney transplantation and (bilateral) nephrectomy through a midline is feasible and safe in polycystic disease

et al. 2017

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In Eurotransplant, 50% of simultaneous liver kidney transplantations (SLK) are performed for polycystic disease. Classically, liver and kidney are transplanted in two steps: liver through a subcostal incision, kidney through a separate oblique incision. Liver and kidney volume can make this ‘two-step’ procedure challenging, especially if simultaneous native nephrectomy is indicated. A ‘one-step’ SLK through a xiphopubic laparotomy might be a safe alternative, facilitating mobilization of the voluminous polycystic liver and native nephrectomy whilst offering access to iliac fossae for kidney transplantation. One-step SLK procedures for polycystic disease were introduced in 08/2013 at IKEM Prague (n = 6) and 11/2014 at University Hospitals Leuven (n = 6). Feasibility and safety of the one-step technique were investigated. We compared surgical data and outcomes obtained with the one-step technique to all consecutive two-step procedures performed for polycystic disease at the University Hospitals Leuven between 2008–2014 (n = 23). Median (interquartile range) are given. One-step SLK offered broad and adequate exposure for the hepatectomy, nephrectomies and transplantations, which were all uneventful. Morbidity, patient (100% vs 91%, p = 0.53) and graft survival (100% graft survival for liver and kidney in both groups) were comparable between one-step and two-step SLK. Liver cold ischaemia time was comparable [6.0 (4.4–7.6) vs. 7.1 (3.9–7.3), p = 0.077], kidney cold ischaemia time was shorter in one-step compared to two-step SLK [8.1 (6.4–9.3) vs. 11.7 (10.0–14.0), p<0.001)]. Total procedural time was also shorter in one-step compared to two-step SLK [6.8 (4.1–9.3) vs. 9.0 (8.7–10.1), p = 0.032], while all underwent bilateral (67%) or unilateral (33%) nephrectomy (compared to 0% and 52% in two-step SLK, respectively). In one-step SLK, 67% received a pre-emptive kidney transplant compared to 46% in two-step SLK. 5/12 two-step SLK became dialysis dependant after pre-transplant nephrectomy, the 4 dialysis-dependant patients with one-step SLK had not undergone pre-transplant nephrectomy. In conclusion, one-step SLK for polycystic disease is feasible and safe.

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“…The prevalence of chronic kidney disease (CKD) in patients with cirrhosis has not been reported, but the increasing prevalence of both CKD and chronic liver disease suggests that the combination is likely to be increasingly seen. Concomitant hepatic and renal disease due to polycystic kidney disease with hepatic involvement is the most common indication for combined liver‐kidney transplantation, followed by renal‐hepatic disease attributable to viral hepatitis (7). Renal failure requiring dialysis develops in 18% of patients following liver transplantation at 5 years (8).…”

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confidence: 99%

Renal Replacement Therapy in Patients with Chronic Liver Disease

Howard

Teitelbaum

2005

Seminars in Dialysis

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As the prevalence of chronic liver disease and chronic kidney disease (CKD) increase, clinicians are likely to be increasingly faced with difficult diagnostic, treatment, and ethical challenges when facing both of these diseases in a single patient. Alterations in creatinine formation and elimination in cirrhotic patients render creatinine-based estimates of glomerular filtration rate and dialysis adequacy less accurate in this population. Furthermore, differentiating signs and symptoms of uremia from hepatic disease may be difficult and clear indications for renal replacement therapy (RRT) in these patients have not been defined. Hemodialysis is associated with a high rate of complications and has not been shown to prolong life in cirrhotic patients with acute renal failure (ARF), but has not been carefully examined in those with CKD. Peritoneal dialysis is, similarly, unhelpful in chronic liver disease complicated by ARF, but has been found to be a viable option in some cirrhotic patients with CKD. Continuous RRT is generally tolerated by patients with decompensated cirrhosis and either acute or chronic renal failure and may act to bridge patients to liver transplantation. Given the poor underlying survival of cirrhotic patients with renal failure, clinicians should carefully consider the utility of RRT in each patient.

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Results of combined and sequential liver-kidney transplantation

Cited by 58 publications

References 49 publications

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

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

Simultaneous liver kidney transplantation and (bilateral) nephrectomy through a midline is feasible and safe in polycystic disease

Renal Replacement Therapy in Patients with Chronic Liver Disease

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