Native renal function after combined liver-kidney transplant for type 1 hepatorenal syndrome: initial report on the use of postoperative Technetium-99 m-mercaptoacetyltriglycine scans

Abstract

SummaryType 1 hepatorenal syndrome (HRS) is characterized by rapid deterioration of renal function. We sought to assess native kidney function after combined kidney-liver transplant (CLKTx) performed for type 1 HRS. We performed a retrospective, cross-sectional, single-center study. All patients with Type 1 HRS who received a CLKTx at the University of California, San Francisco from 1997 to 2007 were screened for enrollment. Patients with a baseline estimated glomerular filtration rate (eGFR) ! 30 ml/min/1.73 m 2 were eligible. Twenty-three patients were identified and consented to receive a Technetium-99 m-mercaptoacetyltriglycine (MAG3) nuclear scan to measure the native kidney contribution to overall renal function. Only 4 of the 23 subjects (17.4%) demonstrated native renal function that consisted of a contribution ! 50% of total renal function. Several factors and comorbidities such as age, gender, race, duration of HRS, need for and duration of renal replacement therapy, need for pressors, urine sodium, proteinuria, and use of octreotide/midodrine were analyzed and not found to be significant in predicting native renal function. The assessment of post-transplant native renal function following CLKTx may allow for improved accuracy in identifying the patients in need of CLKTx, and thus allow for greater optimization of dual-organ allocation strategies in patients with concomitant liver and renal failure.

Renal outcomes of simultaneous liver–kidney transplantation compared to liver transplant alone for candidates with renal dysfunction

“…In this study, RD-SLKT recipients with a pre-operative diagnosis of type 1 HRS (baseline GFR ≥30 mL/min/1.73 m 2 ) underwent technetium-99 m-mercaptoacetyltriglycine nuclear scans to measure the native kidney contribution to the overall renal function. Only four of the 23 subjects (17.4%) demonstrated native renal function that consisted of a contribution ≥50% of total renal function (21). We would argue that there are and that there will always be insufficient data and knowledge for flawless decision making (32).…”

“…Our examination of both survival and renal outcomes for the RD-LTA and RD-SLKT cohorts suggests that our single center decision-making process for selecting transplant type has been imperfect. There have been errors in both directions: A modest number of RD-LTA recipients might have benefited from RD-SLKT as discussed above while a modest number of RD-SLKTs were likely unnecessary as we have previously reported (21). In this study, RD-SLKT recipients with a pre-operative diagnosis of type 1 HRS (baseline GFR ≥30 mL/min/1.73 m 2 ) underwent technetium-99 m-mercaptoacetyltriglycine nuclear scans to measure the native kidney contribution to the overall renal function.…”

“…The higher rate of early post‐transplant mortality for SLKT compared to ESRD recipients exacerbates the sense that kidneys are unnecessarily lost. Finally, the debate has been further fueled by reports documenting “three functioning kidneys” after SLKT from several groups , including ours .…”

Management of renal failure in end‐stage liver disease: A critical appraisal

“…Current OPTN guidelines for SLKT listing criteria are limited by inaccurate assessment of GFR at the time of transplant and by discordance between guidelines and actual native kidney recovery after LT. In reports from 2 UNOS regions, 101 SLKT recipients underwent radionuclide renal scans after transplant: an astounding 46% had functioning native kidneys with GFR > 20 mL/minute, which would not usually qualify them for kidney transplant listing. Kidney biomarkers have been proposed to address this gap.…”

Utility in Treating Kidney Failure in End-Stage Liver Disease With Simultaneous Liver-Kidney Transplantation

“…However, kidney failure in ESLD may reverse with liver transplant and time alone 6–8 . Existing clinical criteria differentiate poorly among patients who will recover and those who will not 9–11 . Under-transplanting SLK may thus lead to worse survival and eventual dialysis-dependence in liver transplant recipients, whereas over-transplanting SLK may lead to organ wastage and decreased access for kidney transplant candidates without liver disease.…”