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

Abstract

Liver-kidney transplantation (LKT) should be reserved for those recipients with primary disease affecting both organs. However, increasing transplant list waiting times have increased the development and duration of acute renal failure before liver transplantation. Furthermore, the need for posttransplant calcineurin inhibitors can render healing from acute renal failure difficult. Because of the increasing requests for and controversy over the topic of a kidney with a liver transplant (OLT) when complete failure of the kidney is not known, the following article will review the impact of renal failure on liver transplant outcome, treatment of peri-OLT renal failure, rejection rates after LKT, survival after LKT, and information on renal histology and progression of disease into the beginnings of an algorithm for making a decision about combined LKT. (Liver Transpl 2002;8:193-211.)

Chronic Kidney Disease after Nonrenal Solid-Organ Transplantation

“…Additional studies include detailed urinalysis, urine sodium, urine protein/creatinine ratio measurement, and ultrasound to assess renal size and morphology. Although some have advocated a pretransplantation kidney biopsy, 101 we believe that biopsy has a limited ability to predict the degree of recovery of kidney function or time to ESRD after liver transplantation. As such, routine renal biopsy should be considered investigational.…”

“…99,100 The decision for SLKT should be based on multiple factors, including duration and degree of kidney dysfunction, potential for renal recovery after liver transplantation alone, and the impact of dual transplantation on recipient survival. 101 By conventional criteria, current United Network for Organ Sharing regulations mandate that patients can be listed for kidney transplantation alone only once their estimated GFR is Յ20 ml/min, representing advanced stage 4 CKD. Recognizing that 90% of liver recipients will have some degree of CKD after transplantation, 8 our institutional practice has been to restrict SLKT to patients who are projected to need listing for a kidney within 12 mo after receiving a liver.…”

Hepatorenal Syndrome

“…Nevertheless, LKT still is not justifiable in patients with HRS because of their reasonable chance of renal recovery and the increasing number of patients who are placed on the waiting list for kidney transplantation (138,139). LKT may be justifiable in those with prolonged duration of RRT pretransplantation, history of previous renal failure, or biopsy findings consistent with chronic kidney disease (139,140). The introduction of the MELD has increased both the number of liver patients who receive a transplant with elevated serum creatinine and the number of LKT being performed (139,141).…”

Results of combined and sequential liver-kidney transplantation

“…Aside from regular careful kidney evaluation, an increased renal resistance index measured by duplex ultrasound reliably identifies patients at risk for progressive renal disease 57 and could help to identify patients best suited for a combined transplantation. 58 In summary, the retrospective evaluation provides a center experience with combined liver-kidney transplantation over a period of 15 years. Given the learning curve and the scarcity of available organs, indications should be considered after careful investigation, particularly regarding renal dysfunction and the general status of the patient.…”