J Korean Soc Transplant.  2010 Dec;24(4):243-247.

Multiple Organ Transplantation: Combined Liver-Kidney Transplantation

• Kim MS

Abstract

Coexisting end stage liver disease (ESLD) and end stage renal disease (ESRD) for a patient on dialysis is a standard indication for a combined liver-kidney transplantation (CLKT). A survival advantage after CLKT has been verified in liver transplant candidates with significant kidney dysfunction due to chronic kidney disease (CKD) or acute kidney injury (AKI). The severity (glomerular filtration rate (GFR) < or =30 mL/min) and duration (more than 8~12 weeks) of kidney dysfunction are strong determinants for the selection of CLKT candidates. The CLKT patient survival rate is superior to that of liver transplant alone in candidates with a serum creatinine >2.0 mg/dL or who are on dialysis. Because of the immunological modulation effect of the liver graft, post-transplant CLTX results in a lower incidence of acute rejection and higher long-term censored graft survival rate in kidney transplant recipients. Despite the advantages of CLKT, the CLKT waiting list is extremely rare in Korea (0.80%, 67/3,717, from recent Korean Network for Organ Sharing (KONOS) data on March 2010). The narrow indications for CLKT (only ESRD candidates on dialysis are accepted for CLKT) and inferior ranking of CLKT for kidney allocation is a pitfall of the multi-organ allocation rule in KONOS.

Keyword

Multiple organ transplantation; Combined liver and kidney transplantation; Allocation

MeSH Terms

Acute Kidney Injury
Creatinine
Dialysis
End Stage Liver Disease
Filtration
Graft Survival
Humans
Imidazoles
Incidence
Kidney
Kidney Failure, Chronic
Korea
Liver
Nitro Compounds
Rejection (Psychology)
Renal Insufficiency, Chronic
Survival Rate
Transplants
Waiting Lists
Creatinine
Imidazoles
Nitro Compounds

Reference

References

1). The U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients (OPTN/SRTR). 2009 OPTN/SRTR Annual Report: Transplant Data 1999–2008 [Internet]. USA: U.S. Department of Health and Human Services;. 2009. [cited 2010 November 12]. Available from. http://optn.transplant.hrsa.gov/ar2009/default.htm.

2). The U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients (OPTN/SRTR). View Data Reports-National Data [Internet]. USA: U.S. Department of Health & Human Services;2009. [cited 2010 November 12]. Available from. http://optn.transplant.hrsa.gov/latestData/viewDataReports.asp.

3). Korean Network for Organ Sharing (KONOS). 2008 Annual Data Report. Seoul: KONOS;2009. p. 28–9. (국립장기이식관리센터. 2008 장기이식 통계연보. 서울: 국립장기이식관리센터; 2009: 28–9.).

4). Eason JD, Gonwa TA, Davis CL, Sung RS, Gerbe D, Bloom RD. Proceedings of Consensus Conference on Simultaneous Liver Kidney Transplantation (SLK). Am J Transplant. 2008; 8:2243–51.

5). Davis CL, Feng S, Sung R, Wong F, Goodrich NP, Melton LB, et al. Simultaneous liver-kidney transplantation: evaluation to decision making. Am J Transplant. 2007; 7:1702–9.

6). Bahirwani R, Campbell MS, Siropaides T, Markmann J, Olthoff K, Shaked A, et al. Transplantation: impact of pretransplant renal insufficiency. Liver Transpl. 2008; 14:665–71.

7). Wadei HM, Geiger XJ, Cortese C, Mai ML, Kramer DJ, Rosser BG, et al. Kidney allocation to liver transplant candidates with renal failure of undetermined etiology: role of percutaneous renal biopsy. Am J Transplant. 2008; 8:2618–26.

8). Campbell MS, Kotlyar DS, Brensinger CM, Lewis JD, Shetty K, Bloom RD, et al. Renal function after orthotopic liver transplantation is predicted by duration of pretransplantation creatinine elevation. Liver Transpl. 2005; 11:1048–55.

9). Ruiz R, Kunitake H, Wilkinson AH, Danovitch GM, Farmer DG, Ghobrial RM, et al. Long-term analysis of combined liver and kidney transplantation at a single center. Arch Surg. 2006; 141:735–41. discussion 741–2.

10). Rasmussen A, Davies HS, Jamieson NV, Evans DB, Calne RY. Combined transplantation of liver and kidney from the same donor protects the kidney from rejection and improves kidney graft survival. Transplantation. 1995; 59:919–21.

11). Opelz G, Margreiter R, Dohler B. Prolongation of long-term kidney graft survival by a simultaneous liver transplant: the liver does it, and the heart does it too. Transplantation. 2002; 74:1390–4. discussion 1370–1.

12). Starzl TE, Demetris AJ, Murase N, Ildstad S, Ricordi C, Trucco M. Cell migration, chimerism, and graft acceptance. Lancet. 1992; 339:1579–82.

13). Sanchez EQ, Klintmalm GB. Combined liver-kidney transplantation. Busuttil RW, Klintmalm GB, editors. Transplantation of the Liver. 2nd ed.Philadelphia: Elsevier Saunders;2005. p. 803–13.

14). Neumann UP, Lang M, Moldenhauer A, Langerehr JM, Glanemann M, Kahl A, et al. Significance of a T-lymphocy-totoxic crossmatch in liver and combined liver-kidney transplantation. Transplantation. 2001; 71:1163–8.

15). Reichman TW, Marino SR, Milner J, Harland RC, Cochrane A, Millis JM, et al. Acute humoral rejection in an ABO compatible combined liver-kidney transplant – the kidney is not always protected. Am J Transplant. 2009; 9:1957–60.

16). Baccaro ME, Pepin MN, Guevara M, Colmenero J, Torregrosa JV, Martin-Llahi M, et al. Combined liver-kidney transplantation in patients with cirrhosis and chronic kidney disease. Nephrol Dial Transplant. 2010; 25:2356–63.

17). Gonwa TA, McBride MA, Anderson K, Mai ML, Wadei H, Ahsan N. Continued influence of preoperative renal function on outcome of orhtotopic liver transplant (OLTX) in the US: where will MELD led us? Am J Transplant. 2006; 6:2651–9.

18). Gonwa TA, Mai ML, Melton LB, Hays SR, Goldstein RM, Levy MF, et al. End-stage renal disease (ESRD) after orthotopic liver transplantation (OLTX) using calcineurin-based immunotherapy: risk of development and treatment. Transplantation. 2001; 72:1934–9.

19). Simpson N, Cho YW, Cicciarelli JC, Selby RR, Fong TL. Comparison of renal allograft outcomes in combined liver-kidney transplantation versus subsequent kidney transplantation in liver transplant recipients: Analysis of UNOS Database. Transplantation. 2006; 82:1298–303.

20). Al Riyami D, Alam A, Badovinac K, Ivis F, Trpeski L, Cantarovich M. Decreased survival in liver transplant patients requiring chronic dialysis: a Canadian experience. Transplantation. 2008; 85:1277–80.