Combined liver and kidney transplantation in patients with chronic nephritis associated with end-stage liver disease

Abstract

A variety of renal diseases can be associated with end-stage liver diseases requiring orthotopic liver transplantation (OLT), including cirrhosis-associated glomerulonephritis (GN), and nephropathy unrelated to the liver disease. A retrospective survey showed that nine patients undergoing liver transplantation in our centre had histologically proven GN or interstitial nephritis with renal failure and/or nephrotic-range proteinuria, and experienced severe complications post-OLT since nephrotoxic immunosuppressive drugs (CsA and FK506) could not be adequately given. Four of the nine patients died. Therefore, combined liver-kidney transplantation has been suggested as first choice treatment in such patients. From January 1990 to February 1994, in patients with end-stage liver disease referred for OLT, and who presented with unexplained renal function impairment and/or significant proteinuria, severe nephropathy was confirmed by renal biopsy in nine: four mesangiocapillary GN with immune deposits, one membranous nephropathy, two diabetic glomerulosclerosis and two interstitial nephritis. All underwent liver transplantation immediately followed by kidney transplantation. The postoperative period was uneventful, and neither death nor renal failure were recorded. Combined transplantation resulted in all patients in the normalization of renal function, and in the disappearance of proteinuria within the first postoperative month. From 6 months to 4 years post-transplant, the renal function remained within normal ranges in all patients. Routine renal transplant biopsy was performed in two patients with pre-transplant cirrhosis-associated GN, and showed no evidence of recurrence of the original nephropathy. We conclude that combined liver-kidney transplantation is an adequate therapeutic option in patients with end-stage liver disease associated with advanced kidney disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Pathophysiology of renal disease associated with liver disorders: Implications for liver transplantation. Part I

“…Time waiting for a transplant also is increasing; there has been a decline in the percentage of liver transplant candidates undergoing transplantation within 60 days of listing from 18.1% in 1995 to 11.3% in 1998, 5 and the average waiting time for a status 2A recipient has increased from 11 to 12 days in 1998 and 1999 (range, 7 to 19 days) to 41 days in 2000 (range, 26 to 54 days). 6 The waiting time for liver transplant candidates undergoing dialysis also has increased, with one study reporting an increase from 11.5 to 44.5 days.…”

“…Renal diseases may be divided into several categories, including glomerulonephritis (membranoproliferative glomerulonephritis [MPGN], membranous nephropathy, immunoglobulin A [IgA] nephropathy, mesangial proliferative glomerulonephritis, vasculitis [both antineutrophil cytoplasmic autoantibody and/or anti-glomerular basement membrane antibody positive], and fibrillary glomerulopathy), tubulointerstitial nephritis (Sjögren's syndrome, sarcoidosis, secondary oxalosis), metabolic diseases (primary hyperoxaluria, methylmalonic aciduria), and structural diseases (cystic renal disease). 1,[10][11][12][13][14][15][16][17] Primary biliary cirrhosis and primary sclerosing cholangitis most often are associated with antineutrophil cyto-plasmic autoantibody-positive vasculitis and membranous nephropathy. 18,19 Hepatitis C virus (HCV) infection is associated primarily with MPGN, but fibrillary glomerulonephritis also is seen.…”

Identification of patients best suited for combined liver[ndash ]kidney transplantation: Part II

“…38 Mortality most often is caused by dialysis access-related sepsis. 10,16,39,42 In addition to sepsis, patients are plagued with blood pressure instability and a risk for both bleeding and thrombosis. Renal transplantation appears to be a better option than dialysis for the treatment of ESRD in liver transplant recipients, evidenced by the 6-year patient survival rate after developing ESRD of 27% for patients on dialysis therapy compared with 71.4% for those subsequently receiving a renal transplant.…”

“…Early acute kidney rejection rates in combined transplantation are on average less than 10% (Table 10). 12,42,43,[46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61]65,80 This is compared with rejection rates of 30% to 50% reported in the literature for temporally matched kidney-only transplant recipients. 65 Thus, even with less HLA matching and a positive cross-match, renal rejection rates appear to be lower when a liver allograft is placed concurrently ( 3).…”

Results of combined and sequential liver-kidney transplantation

“…Since the first combined liver-kidney transplantation performed by Margreiter et al, 11 a number of simultaneous liver and kidney transplantations in patients suffering from concurrent irreversible failure of both organs were initiated. Several centers have reported successful outcomes after combined transplantation in patients with acquired or hereditary disorders affecting both the liver and the kidney, [12][13][14][15][16][17][18][19][20][21][22] although advanced renal dysfunction had previously been considered a contraindication to liver transplantation. 23 Beyond this, it has been assumed that the liver plays a role in protecting the kidney from acute rejection, 12,14,19,24,25 although there have also been reports of contrary results.…”