Simultaneous Transplants Boost Odds
David A. Gerber, MD
MARCO ISLAND, Fla.—Combined liver and kidney transplantation (CLKT) may provide an immunologic benefit compared with first transplanting a liver and then a kidney, according to researchers. Graft rejection risk is reduced by 5%-10%, data show.
“It is a small but significant benefit,” said David A. Gerber, MD, associate professor of surgery and chief of abdominal transplant surgery at the University of North Carolina in Chapel Hill.
CLKT is often a treatment for patients with hepatorenal syndrome (HRS), a liver-failure complication that has a poor prognosis without transplantation. Type 1 HRS, or liver failure accompanied by rapidly progressive renal failure, is associated with a median patient survival of only two to four weeks.
Patients with type 2 HRS, or liver failure accompanied by a slower deterioration of renal function, tend to fare better, with a median survival of approximately six months. He spoke here at the American Society of Transplant Surgeons 9th Annual State of the Art Winter Symposium.
The overall course of HRS is unpredictable and likely influenced by the presence of other perioperative conditions or events. Recovery of renal function following CLKT may be delayed by hypovolemia, use of vasopressors, infection, subsequent reoperations, and nephrotoxic agents.
Current data suggest older patients (aged 65 years and older) and those on dialysis prior to either liver transplant alone or CLKT tend to have poorer survival than patients under the age of 65 who were not requiring dialysis prior to their transplant.
When treating patients with recent-onset renal insufficiency, the decision to perform CLKT vs. orthotopic liver transplant (OLT) is often difficult. It has been demonstrated that the duration of pretransplantation renal dysfunction predicts six-to-12-month creatinine levels post-OLT.
In this study, the researchers found that after adjusting for baseline characteristics, CLKT patients had lower creatinine levels than OLT patients at both six and 12 months post-transplantation. The researchers also found that the duration of renal dysfunction and not the cause of renal dysfunction predicted renal outcome in OLT-alone patients.
A consensus conference sponsored by several societies recently convened to examine CLKT and determine appropriate indications for it. A prospective data registry and standard listing criteria for CLKT candidates were established.
It is still being determined how patients will be listed for CLKT. It is likely that approval will be granted for patients with end-stage renal disease, cirrhosis and symptomatic portal hypertension or hepatic vein wedge pressure gradient of 10 mm Hg or greater; liver failure and CKD with glomerular filtration rate of 30 mL/min/1.73 m2 or less; acute kidney injury or hepatorenal syndrome with creatinine levels of 2.0 mg/dL or greater and dialysis for eight weeks or longer; or liver failure and CKD with biopsy showing greater than 30% glomerulosclerosis or 30% fibrosis. Dr. Gerber said that depending on the automatic listing criteria the RRBs will need to evaluate all other requests to determine appropriateness.
“Nephrologists should care about this because they need to be engaged in the process,” Dr. Gerber told Renal & Urology News. “They need to help identify which patients truly need a combined liver-kidney transplant. With the complexity of these patients we don't want the transplant surgeons and/or the hepatologists making this decision in isolation, without input from the nephrologists.”
The number of CLKT procedures has increased substantially in the past decade, Dr. Gerber noted, jumping from 134 in 2001 to 440 in 2007.