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1
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Alotaibi ME, Kant S. Dual organ transplantation: Pancreas and Liver in the kidney axis. Curr Opin Nephrol Hypertens 2025; 34:164-169. [PMID: 39639839 DOI: 10.1097/mnh.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2024]
Abstract
PURPOSE OF REVIEW This article explores the benefits and challenges of dual organ transplants. RECENT FINDINGS Simultaneous liver-kidney transplant has become a valuable option for patients with both liver and kidney failure, especially since the introduction of clearer eligibility guidelines in 2017. When done for the appropriate candidate, it can significantly improve survival and quality of life. Similarly, simultaneous pancreas-kidney transplantation provides significant advantages for patients with diabetes-related kidney failure by addressing both glycemic control and kidney function, with significant improvement in diabetes associated complications and survival. SUMMARY While these procedures are complex, they offer promising solutions for managing difficult multiorgan conditions. Ongoing research and personalized patient care will be key to maximizing their benefits.
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Affiliation(s)
- Manal E Alotaibi
- Department of Medicine, Medical College, Umm Al-Qura University (UQU), Makkah, Saudi Arabia
| | - Sam Kant
- Department of Renal Medicine, St. Vincent's University Hospital, University College Dublin, Dublin, Ireland
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2
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Kaufman DM, Perkins JD, Bakthavatsalam R, Leca N, Sibulesky L. Simultaneous Liver and Kidney Transplantation in Patients Aged 70 y and Older: Proceed With Caution. Transplant Direct 2024; 10:e1683. [PMID: 39035115 PMCID: PMC11259391 DOI: 10.1097/txd.0000000000001683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/30/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND The number of elderly patients aged 70 y and older with liver and kidney failure is increasing, mainly because of increasing prevalence of metabolic dysfunction-associated steatohepatitis. At present, limited data are available on the outcomes of elderly patients who fit the criteria for dual organ transplantation since the implementation of the simultaneous liver and kidney (SLK) allocation policy. METHODS We performed a retrospective analysis of the Organ Procurement and Transplantation Network database of adults aged 18 y and older undergoing SLK and kidney transplantation only from August 11, 2017, to December 31, 2022. We examined patient and graft survivals and compared the outcomes of the recipients aged 70 y and older undergoing SLK transplantation to those who received kidney transplant alone and kidney after liver transplant. RESULTS During the study period, there has been a significant rise in the number of patients aged 70 y and older undergoing SLK transplantation, with 6 patients undergoing SLK transplantation in 2017 and 63 in 2021. Patients aged 70 y and older had significantly lower survival with 82.9% at 1 y and 66.5% at 3 y compared with 89.3% and 78.8% in the 50-69 y age group and 93.2% and 88.6% in the 18-49 y age group, respectively. Overall, kidney allograft survival was significantly lower in the 70 y and older group, with 80.9% at 1 y and 66.4% at 3 y compared with 91.1% and 75.5%, respectively, in those undergoing kidney transplant alone. There was no difference in kidney allograft survival in those undergoing SLK and kidney after liver transplantation. CONCLUSIONS Although the outcomes are inferior in recipients of SLK transplant aged 70 y and older, chronologic age should not preclude them from undergoing transplantation. Kidney transplantation after liver transplantation could be considered to avoid futile transplants.
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Affiliation(s)
- Daniel M. Kaufman
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - James D. Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, WA
| | - Ramasamy Bakthavatsalam
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Nicolae Leca
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, WA
- Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Lena Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), University of Washington, Seattle, WA
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3
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Lum EL, Bunnapradist S, Wiseman AC, Gurakar A, Ferrey A, Reddy U, Al Ammary F. Novel indications for referral and care for simultaneous liver kidney transplant recipients. Curr Opin Nephrol Hypertens 2024; 33:354-360. [PMID: 38345405 PMCID: PMC10990015 DOI: 10.1097/mnh.0000000000000970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
PURPOSE OF REVIEW Kidney dysfunction is challenging in liver transplant candidates to determine whether it is reversible or not. This review focuses on the pertinent data on how to best approach liver transplant candidates with kidney dysfunction in the current era after implementing the simultaneous liver kidney (SLK) allocation policy and safety net. RECENT FINDINGS The implementation of the SLK policy inverted the steady rise in SLK transplants and improved the utilization of high-quality kidneys. Access to kidney transplantation following liver transplant alone (LTA) increased with favorable outcomes. Estimating GFR in liver transplant candidates remains challenging, and innovative methods are needed. SLK provided superior patient and graft survival compared to LTA only for patients with advanced CKD and dialysis at least 3 months. SLK can provide immunological protection against kidney rejection in highly sensitized candidates. Post-SLK transplant care is complex, with an increased risk of complications and hospitalization. SUMMARY The SLK policy improved kidney access and utilization. Transplant centers are encouraged, under the safety net, to reserve SLK for liver transplant candidates with advanced CKD or dialysis at least 3 months while allowing lower thresholds for highly sensitized patients. Herein, we propose a practical approach to liver transplant candidates with kidney dysfunction.
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Affiliation(s)
- Erik L. Lum
- Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - Suphamai Bunnapradist
- Department of Medicine, University of California Los Angeles, Los Angeles, California
| | | | - Ahmet Gurakar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Antoney Ferrey
- Department of Medicine, University of California Irvine, Orange, California, USA
| | - Uttam Reddy
- Department of Medicine, University of California Irvine, Orange, California, USA
| | - Fawaz Al Ammary
- Department of Medicine, University of California Irvine, Orange, California, USA
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Innanen T, Sallinen V, Helanterä I, Eerola V, Nordin A, Åberg F. Risk and prediction of kidney failure early after liver transplantation. Scand J Gastroenterol 2024; 59:461-468. [PMID: 38069811 DOI: 10.1080/00365521.2023.2291992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/03/2023] [Indexed: 04/04/2024]
Abstract
BACKGROUND Kidney disease is common after liver transplantation (LT), but postoperative kidney failure is difficult to predict. Current guidelines recommend simultaneous liver-kidney transplantation (SLKT) in patients with pre-LT estimated glomerular filtration rate (eGFR) below 30-40 mL/min, which might be too liberal. The aim of this study was to evaluate the risk of kidney failure after LT. We also assessed the predictive ability of pretransplantation eGFR using various equations. METHODS This single-center study included patients undergoing primary LT 2006-2020. Patients undergoing simultaneous liver-kidney transplantations or on dialysis before LT were analysed separately. We calculated 5 different eGFR equations measured just before LT and assessed their predictive ability using Kaplan-Meier cumulative incidence estimates. RESULTS Among 556 LT patients with a median follow-up of 5.0 years (IQR 2.0-8.5), 20 developed kidney failure during follow-up, 7 of them within 1-year post LT. Six of these 7 suffered from major perioperative complications. Depending on the eGFR equation used, the incidence of kidney failure within 1-year was 3.9-6.7% at pre-LT eGFR-values <30 mL/min, 1.2-3.1% at eGFR 30-60 mL/min, and 0.6-0.9% at eGFR >60 mL/min. CONCLUSIONS Kidney failure within 1-year post-LT could not be reliably predicted by pre-LT eGFR. However, kidney failure was uncommon even in patients with severely reduced pre-LT glomerular filtration rate (eGFR <30 mL/min), and extremely rare in patients unaffected by major perioperative complications. Our data prompts further consideration regarding the guidelines for SLKT in patients with a reduced preoperative eGFR.
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Affiliation(s)
- Tuija Innanen
- Transplantation and Liver Surgery Unit, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Transplantation and Liver Surgery Unit, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ilkka Helanterä
- Transplantation and Liver Surgery Unit, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Verner Eerola
- Transplantation and Liver Surgery Unit, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Arno Nordin
- Transplantation and Liver Surgery Unit, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Fredrik Åberg
- Transplantation and Liver Surgery Unit, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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5
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Fernández-Carrillo C, Li Y, Ventura-Cots M, Argemi J, Dai D, Clemente-Sánchez A, Duarte-Rojo A, Behari J, Ganesh S, Jonassaint NL, Tevar AD, Hughes CB, Humar A, Molinari M, Landsittel DP, Bataller R. Poor Outcomes of Patients With NAFLD and Moderate Renal Dysfunction or Short-Term Dialysis Receiving a Liver Transplant Alone. Transpl Int 2022; 35:10443. [PMID: 36568138 PMCID: PMC9784907 DOI: 10.3389/ti.2022.10443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 10/27/2022] [Indexed: 12/13/2022]
Abstract
The outcomes of patients with moderate renal impairment and the impact of liver disease etiology on renal function recovery after liver transplant alone (LTA) are largely unknown. We explored whether NAFLD patients with pre-LTA moderate renal dysfunction (GFR 25-45 ml/min/1.73 m2) may be more susceptible to develop post-LTA severe renal dysfunction (GFR<15 ml/min/1.73 m2) than ALD patients, as well as other overall outcomes. Using the UNOS/OPTN database, we selected patients undergoing liver transplant for NAFLD or ALD (2006-2016), 15,103 of whom received LTA. NAFLD patients with moderate renal dysfunction were more likely to develop subsequent GFR<15 ml/min/1.73 m2 than ALD patients (11.1% vs. 7.38%, p < 0.001). Patients on short-term dialysis pre-LTA (≤12 weeks) were more likely to develop severe renal dysfunction (31.7% vs. 18.1%), especially in NAFLD patients, and were more likely to receive a further kidney transplant (15.3% vs. 3.7%) and had lower survival (48.6% vs. 50.4%) after LTA (p < 0.001 for all). NAFLD was an independent risk factor for post-LTA severe renal dysfunction (HR = 1.2, p = 0.02). NAFLD patients with moderate renal dysfunction and those receiving short-term dialysis prior to LTA are at a higher risk of developing subsequent severe renal dysfunction. Underlying etiology of liver disease may play a role in predicting development and progression of renal failure in patients receiving LTA.
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Affiliation(s)
- Carlos Fernández-Carrillo
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,CIBERehd. Instituto de Salud Carlos III, Madrid, Spain,Gastroenterología y Hepatología, IDIPHISA, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Yaming Li
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Meritxell Ventura-Cots
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,CIBERehd. Instituto de Salud Carlos III, Madrid, Spain
| | - Josepmaria Argemi
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,CIBERehd. Instituto de Salud Carlos III, Madrid, Spain
| | - Dongling Dai
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Ana Clemente-Sánchez
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,CIBERehd. Instituto de Salud Carlos III, Madrid, Spain
| | - Andres Duarte-Rojo
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Jaideep Behari
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Swaytha Ganesh
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Naudia L. Jonassaint
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Amit D. Tevar
- Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Christopher B. Hughes
- Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Abhinav Humar
- Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Michele Molinari
- Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Douglas P. Landsittel
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ramon Bataller
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,*Correspondence: Ramon Bataller,
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Lia D, Grodstein EI. Kidney Allocation Issues in Liver Transplantation Candidates with Chronic Kidney Disease and Severe Kidney Liver Injury. Clin Liver Dis 2022; 26:283-289. [PMID: 35487611 DOI: 10.1016/j.cld.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The number of liver transplant candidates with concomitant renal disease has been steadily rising since the implementation of MELD-based allocation in 2002. Consequently, the number of simultaneous liver-kidney (SLK) transplants being performed each year has also increased. However, the establishment of well-defined criteria for when to choose SLK over liver transplant alone has lagged behind. The lack of clear guidelines has worsened an already large shortage of transplantable kidneys. This article further explores the rationale for and outlines the implementation of the SLK allocation policy.
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Affiliation(s)
- Daniel Lia
- Transplant Surgery Fellowship, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 400 Community Drive, Manhasset, NY 11765, USA
| | - Elliot I Grodstein
- Transplant Surgery Fellowship, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 400 Community Drive, Manhasset, NY 11765, USA.
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7
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Chang A, Schaubel DE, Chen M, Abt PL, Bittermann T. Trends and Outcomes of Hypothermic Machine Perfusion Preservation of Kidney Allografts in Simultaneous Liver and Kidney Transplantation in the United States. Transpl Int 2022; 35:10345. [PMID: 35356400 PMCID: PMC8958417 DOI: 10.3389/ti.2022.10345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 01/18/2022] [Indexed: 11/18/2022]
Abstract
Optimal kidney graft outcomes after simultaneous liver-kidney (SLK) transplant may be threatened by the increased cold ischemia time and hemodynamic perturbations of dual organ transplantation. Hypothermic machine perfusion (MP) of kidney allografts may mitigate these effects. We analyzed U.S. trends and renal outcomes of hypothermic non-oxygenated MP vs. static cold storage (CS) of kidney grafts from 6,689 SLK transplants performed between 2005 and 2020 using the United Network for Organ Sharing database. Outcomes included delayed graft function (DGF), primary non-function (PNF), and kidney graft survival (GS). Overall, 17.2% of kidney allografts were placed on MP. Kidney cold ischemia time was longer in the MP group (median 12.8 vs. 10.0 h; p < 0.001). Nationally, MP utilization in SLK increased from <3% in 2005 to >25% by 2019. Center preference was the primary determinant of whether a graft underwent MP vs. CS (intraclass correlation coefficient 65.0%). MP reduced DGF (adjusted OR 0.74; p = 0.008), but not PNF (p = 0.637). Improved GS with MP was only observed with Kidney Donor Profile Index <20% (HR 0.71; p = 0.030). Kidney MP has increased significantly in SLK in the U.S. in a heterogeneous manner and with variable short-term benefits. Additional studies are needed to determine the ideal utilization for MP in SLK.
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Affiliation(s)
- Alex Chang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Douglas E Schaubel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Melissa Chen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Peter L Abt
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Therese Bittermann
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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8
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Simultaneous Liver-Kidney Transplantation and the Use of Intraoperative Dialysis: A Monocenter Study. Transplant Proc 2022; 54:1002-1006. [DOI: 10.1016/j.transproceed.2022.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/18/2022] [Indexed: 11/19/2022]
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9
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[Kidney failure after liver transplantation]. Nephrol Ther 2022; 18:89-103. [PMID: 35151596 DOI: 10.1016/j.nephro.2021.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/11/2021] [Accepted: 11/06/2021] [Indexed: 02/06/2023]
Abstract
One third of cirrhotic patients present impaired kidney function. It has multifactorial causes and has a harmful effect on patients' morbi-mortality before and after liver transplant. Kidney function does not improve in all patients after liver transplantation and liver-transplant recipients are at high risk of developing chronic kidney disease. Causes for renal dysfunction can be divided in three groups: preoperative, peroperative and postoperative factors. To date, there is no consensus for the modality of evaluation the risk for chronic kidney disease after liver transplantation, and for its prevention. In the present review, we describe the outcome of kidney function after liver transplantation, and the prognostic factors of chronic kidney disease to determine a risk stratification for each patient. Furthermore, we discuss therapeutic options to prevent kidney dysfunction in this setting, and highlight the indications of combined liver-kidney transplantation.
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10
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Hendele J, Perkins J, Leca N, Biggins S, Sibulesky L. Optimizing Risk Assessment In Simultaneous Liver and Kidney Transplant: Donor and Recipient Factors Associated With Improved Outcome. Transplant Proc 2022; 54:715-718. [DOI: 10.1016/j.transproceed.2021.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/03/2021] [Accepted: 11/18/2021] [Indexed: 10/18/2022]
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Dasari M, Perkins JD, Hendele JB, Leca N, Biggins SW, Sibulesky L. Prescriptive Analytics Determining Which Patients Undergoing Simultaneous Liver-Kidney Transplant May Benefit From High-Risk Organs. EXP CLIN TRANSPLANT 2021; 19:1303-1312. [PMID: 34951349 DOI: 10.6002/ect.2021.0330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Simultaneous liver-kidney transplant is a treatment option for patients with end-stage liver disease and concomitant irreversible kidney injury. We developed a decision toolto aid transplant programs to advise their candidates for simultaneous liver-kidney transplant on accepting high-risk grafts versus waiting for lower-risk grafts. MATERIALS AND METHODS To find the critical decision factors, we used the prescriptive analytic technique of microsimulation.All probabilities used in the simulation model were calculated from Organ Procurement and Transplantation Network data collected from February 27, 2002 to June 30, 2018. RESULTS The simulated patient population results revealed, on average, that high-risk candidates for simultaneous liver-kidney transplant who accept highrisk organs have 254.8 ± 225.4 weeks of life compared with 285.6 ± 232.4 weeks if they waited for better organs. However, critical decision factors included the specific organ offer rates within individual transplant programs and the rank of the candidate in each program's waitlist. Thus, for programs with lower organ offer rates or for candidates with a rare blood type, a high-risk simultaneous liver-kidney transplant candidate might accept a high-risk organ for longer survival. CONCLUSIONS Our model can be utilized to determine when acceptance of high-risk organs for patients being considered for simultaneous liver-kidney transplant would lead to survival benefit, based on probabilities specific for their program.
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Affiliation(s)
- Mohini Dasari
- From the Department of Surgery, UW Medicine Kidney and Pancreas Transplantation Program, University of Washington, Seattle, Washington, USA
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12
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Sánchez Arco AM, Segura Jiménez I, Plata Illescas C, Castilla Jimena JA, Herrero Torres MDLÁ, Mohamed Chairi MH, Acosta Gallardo C, Arteaga Ledesma M, Villegas Herrera MT, Villar Del Moral JM. Renal Function in Receptors With Simultaneous Liver-Kidney Transplant From the Same Donor. Transplant Proc 2021; 54:45-47. [PMID: 34920882 DOI: 10.1016/j.transproceed.2021.08.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 08/25/2021] [Indexed: 10/19/2022]
Abstract
Controversy surrounds the suitability of simultaneous liver-kidney transplant (SLKT) when compared with sequential transplant. Pretransplant renal failure is a post-transplant mortality predictor, and studies demonstrate worse functioning and lower survival of the renal graft when compared with kidney transplant alone (KTA). BACKGROUND This study compares renal function in patients with SLKT and those who received the contralateral kidney from the same donor. MATERIAL AND METHODS From June 2017 to February 2021, 5 SLKTs were performed in our hospital, and contralateral kidney grafts took place in other Andalusian Modification on Diet in Renal Disease-4 hospitals. Renal function was assessed according to glomerular filtration (GF) by the formula (that uses 4 variables: creatinine, age, sex, and race) during different periods of time; and the average increase of GF during 6 months in both groups was compared. Other factors from donors and receptors were also compared. RESULTS No statistically significant differences between average GF in both groups were found; however, there were statistically significant differences when we compared the GF increase 6 months after the transplant in both groups of patients, being that increase higher in patients with KTA. CONCLUSIONS Despite our small sample size, our study found that patients with SLKT have worse functioning of the kidney graft than those with KTA.
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Affiliation(s)
| | | | | | | | | | | | | | - María Arteaga Ledesma
- General Surgery department, Virgen de las Nieves University Hospital, Granada, Spain
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13
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Wilk AR, Booker SE, Stewart DE, Wiseman A, Gauntt K, Mulligan D, Formica RN. Developing simultaneous liver-kidney transplant medical eligibility criteria while providing a safety net: A 2-year review of the OPTN's allocation policy. Am J Transplant 2021; 21:3593-3607. [PMID: 34254434 DOI: 10.1111/ajt.16761] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 01/25/2023]
Abstract
The OPTN's simultaneous liver-kidney (SLK) allocation policy, implemented August 10, 2017, established medical eligibility criteria for adult SLK candidates and created Safety Net kidney allocation priority for liver-alone recipients with new/continued renal impairment. OPTN SLK and kidney after liver (KAL) data were analyzed (registrations as of December 31, 2019, transplants pre-policy [March 20, 2015-August 9, 2017] vs. post-policy [August 10, 2017-December 31, 2019]). Ninety-four percent of SLK registrations met eligibility criteria (99% CKD: 50% dialysis, 50% eGFR). SLK transplant volume decreased from a record 740 (2017) to 676 (2018, -9%), with a subsequent increase to 728 (2019, 1.6% below 2017 volume). For KAL listings within 1 year of liver transplant, waitlist mortality rates declined post-policy versus pre-policy (27 [95% CI = 20.6-34.7] vs. 16 [11.7-20.5]) while transplant rates increased fourfold (46 [32.2-60.0] vs. 197 [171.6-224.7]). There were 234 KAL transplants post-policy (94% Safety Net priority eligible), and no significant difference in 1-year patient/graft survival vs. kidney-alone (patient: 95.9% KAL, 97.0% kidney-alone [p = .39]; graft: 94.2% KAL, 94.6% kidney-alone [p = .81]). From pre- to post-policy, the proportion of all deceased donor kidney and liver transplants that were SLK decreased (kidney: 5.1% to 4.3%; liver: 9.7% to 8.7%). SLK policy implementation interrupted the longstanding rise in SLK transplants, while Safety Net priority directed kidneys to liver recipients in need with thus far minimal impact to posttransplant outcomes.
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Affiliation(s)
- Amber R Wilk
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Sarah E Booker
- United Network for Organ Sharing, Richmond, Virginia, USA
| | | | | | - Katrina Gauntt
- United Network for Organ Sharing, Richmond, Virginia, USA
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14
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Cullaro G, Sharma P, Jo J, Rassiwala J, VanWagner LB, Wong R, Lai JC, Magee J, Schluger A, Barman P, Patel YA, Walter K, Biggins SW, Verna EC. Temporal Trends and Evolving Outcomes After Simultaneous Liver-Kidney Transplantation: Results from the US SLKT Consortium. Liver Transpl 2021; 27:1613-1622. [PMID: 34265161 PMCID: PMC8982673 DOI: 10.1002/lt.26232] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 06/08/2021] [Accepted: 06/30/2021] [Indexed: 01/13/2023]
Abstract
We aimed to understand the contemporary changes in the characteristics and the determinants of outcomes among simultaneous liver-kidney transplantation (SLKT) recipients at 6 liver transplantation centers in the United States. We retrospectively enrolled SLKT recipients between 2002 and 2017 in the US Multicenter SLKT Consortium. We analyzed time-related trends in recipient characteristics and outcomes with linear regression and nonparametric methods. Clustered Cox regression determined the factors associated with 1-year and overall survival. We enrolled 572 patients. We found significant changes in the clinical characteristics of SLKT recipients: as compared with 2002, recipients in 2017 were older (59 versus 52 years; P < 0.001) and more likely to have chronic kidney disease (71% versus 33%; P < 0.001). There was a marked improvement in 1-year survival during the study period: 89% in 2002 versus 96% in 2017 (P < 0.001). We found that the drivers of 1-year mortality were SLKT year, hemodialysis at listing, donor distance, and delayed kidney allograft function. The drivers of overall mortality were an indication of acute kidney dysfunction, body mass index, hypertension, creatinine at SLKT, ventilation at SLKT, and donor quality. In this contemporary cohort of SLKT recipients, we highlight changes in the clinical characteristics of recipients. Further, we identify the determinants of 1-year and overall survival to highlight the variables that require the greatest attention to optimize outcomes.
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Affiliation(s)
- Giuseppe Cullaro
- Center for Liver Disease and Transplantation, Columbia University College of Physicians and Surgeons, New York, NY
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI
| | - Jennifer Jo
- Division of Gastroenterology and Hepatology and Preventative Medicine-Epidemiology, Northwestern University, Chicago, IL
| | - Jasmine Rassiwala
- Division of Gastroenterology and Hepatology and Preventative Medicine-Epidemiology, Northwestern University, Chicago, IL
| | - Lisa B. VanWagner
- Division of Gastroenterology and Hepatology and Preventative Medicine-Epidemiology, Northwestern University, Chicago, IL
| | - Randi Wong
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA
| | - John Magee
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI
| | - Aaron Schluger
- Department of Internal Medicine, Westchester Medical Center, Westchester, NY
| | - Pranab Barman
- Division of Gastroenterology and Hepatology, University of California, San Diego, San Diego, CA
| | - Yuval A. Patel
- Division of Gastroenterology, Duke University, Durham, NC
| | - Kara Walter
- Division of Gastroenterology and Hepatology, University of California, Los Angeles, Los Angeles, CA
| | - Scott W. Biggins
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, WA
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University College of Physicians and Surgeons, New York, NY
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15
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Westphal SG, Langewisch ED, Miles CD. Current State of Multiorgan Transplantation and Implications for Future Practice and Policy. Adv Chronic Kidney Dis 2021; 28:561-569. [PMID: 35367024 DOI: 10.1053/j.ackd.2021.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/17/2021] [Accepted: 09/28/2021] [Indexed: 12/07/2022]
Abstract
The incidence of kidney dysfunction has increased in liver transplant and heart transplant candidates, reflecting a changing patient population and allocation policies that prioritize the most urgent candidates. A higher burden of pretransplant kidney dysfunction has resulted in a substantial rise in the utilization of multiorgan transplantation (MOT). Owing to a shortage of available deceased donor kidneys, the increased use of MOT has the potential to disadvantage kidney-alone transplant candidates, as current allocation policies generally provide priority for MOT candidates above all kidney-alone transplant candidates. In this review, the implications of kidney disease in liver transplant and heart transplant candidates is reviewed, and current policies used to allocate organs are discussed. Important ethical considerations pertaining to MOT allocation are examined, and future policy modifications that may improve both equity and utility in MOT policy are considered.
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16
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Abstract
One-third of patients with cirrhosis present kidney failure (AKI and CKD). It has multifactorial causes and a harmful effect on morbidity and mortality before and after liver transplantation. Kidney function does not improve in all patients after liver transplantation, and liver transplant recipients are at a high risk of developing chronic kidney disease. The causes of renal dysfunction can be divided into three groups: pre-operative, perioperative and post-operative factors. To date, there is no consensus on the modality to evaluate the risk of chronic kidney disease after liver transplantation, or for its prevention. In this narrative review, we describe the outcome of kidney function after liver transplantation, and the prognostic factors of chronic kidney disease in order to establish a risk categorization for each patient. Furthermore, we discuss therapeutic options to prevent kidney dysfunction in this context, and highlight the indications of combined liver–kidney transplantation.
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17
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Sharma P, Sui Z, Zhang M, Magee JC, Barman P, Patel Y, Schluger A, Walter K, Biggins SW, Cullaro G, Wong R, Lai JC, Jo J, Sinha J, VanWagner L, Verna EC. Renal Outcomes After Simultaneous Liver-Kidney Transplantation: Results from the US Multicenter Simultaneous Liver-Kidney Transplantation Consortium. Liver Transpl 2021; 27:1144-1153. [PMID: 33641218 PMCID: PMC8823286 DOI: 10.1002/lt.26032] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/29/2020] [Accepted: 01/26/2021] [Indexed: 12/19/2022]
Abstract
Simultaneous liver-kidney transplantation (SLKT) is increasingly common in the United States. However, little is known about the renal-related outcomes following SLKT, which are essential to maximize the health of these allografts. We examined the factors impacting renal function following SLKT. This is an observational multicenter cohort study from the US Multicenter SLKT Consortium consisting of recipients of SLKT aged ≥18 years of transplantations performed between February 2002 and June 2017 at 6 large US centers in 6 different United Network for Organ Sharing regions. The primary outcome was incident post-SLKT stage 4-5 chronic kidney disease (CKD) defined as <30 mL/minute/1.73 m2 or listing for kidney transplant. The median age of the recipients (n = 570) was 58 years (interquartile range, 51-64 years), and 37% were women, 76% were White, 33% had hepatitis C virus infection, 20% had nonalcoholic steatohepatitis (NASH), and 23% had alcohol-related liver disease; 68% developed ≥ stage 3 CKD at the end of follow-up. The 1-year, 3-year, and 5-year incidence rates of post-SLKT stage 4-5 CKD were 10%, 12%, and 16%, respectively. Pre-SLKT diabetes mellitus (hazard ratio [HR], 1.45; 95% CI, 1.00-2.15), NASH (HR, 1.58; 95% CI, 1.01-2.45), and delayed kidney graft function (HR, 1.72; 95% CI, 1.10-2.71) were the recipient factors independently associated with high risk, whereas the use of tacrolimus (HR, 0.44; 95% CI, 0.22-0.89) reduced the risk. Women (β = -6.22 ± 2.16 mL/minute/1.73 m2 ; P = 0.004), NASH (β = -7.27 ± 3.27 mL/minute/1.73 m2 ; P = 0.027), and delayed kidney graft function (β = -7.25 ± 2.26 mL/minute/1.73 m2 ; P = 0.007) were independently associated with low estimated glomerular filtration rate at last follow-up. Stage 4-5 CKD is common after SLKT. There remains an unmet need for personalized renal protective strategies, specifically stratified by sex, diabetes mellitus, and liver disease, to preserve renal function among SLKT recipients.
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Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, MI
| | - Zhiyu Sui
- Department of Biostatistics, School of Public Health, Michigan Medicine, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, Michigan Medicine, Ann Arbor, MI
| | - John C. Magee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Pranab Barman
- Division of Gastroenterology and Hepatology, University of California, San Diego, CA
| | - Yuval Patel
- Division of Gastroenterology, Duke University, Durham, NC
| | - Aaron Schluger
- Section of Internal Medicine, Westchester Medical Center, Westchester, NY
| | - Kara Walter
- Division of Digestive Diseases, University of California, Los Angeles, CA
| | - Scott W. Biggins
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, WA
| | - Giuseppe Cullaro
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY
| | - Randi Wong
- Division of Gastroenterology and Hepatology, University of California, San Francisco, CA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, CA
| | - Jennifer Jo
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | - Jasmine Sinha
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | - Lisa VanWagner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY
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18
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Nilles KM, Levitsky J. Current and Evolving Indications for Simultaneous Liver Kidney Transplantation. Semin Liver Dis 2021; 41:308-320. [PMID: 34130337 DOI: 10.1055/s-0041-1729969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This review will discuss the etiologies of kidney disease in liver transplant candidates, provide a historical background of the prior evolution of simultaneous liver-kidney (SLK) transplant indications, discuss the current indications for SLK including Organ Procurement and Transplantation Network policies and Model for End Stage Liver Disease exception points, as well as provide an overview of the safety net kidney transplant policy. Finally, the authors explore unanswered questions and future research needed in SLK transplantation.
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Affiliation(s)
- Kathy M Nilles
- Division of Gastroenterology and Hepatology, Department of Medicine, MedStar Georgetown Transplant Institute, Georgetown University School of Medicine, Washington, District of Columbia
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Department of Medicine, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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19
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Cannon RM, Goldberg DS, Eckhoff DE, Anderson DJ, Orandi BJ, Locke JE. Early Outcomes With the Liver-kidney Safety Net. Transplantation 2021; 105:1261-1272. [PMID: 33741848 DOI: 10.1097/tp.0000000000003365] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND A safety net policy was implemented in August 2017 giving liver transplant alone (LTA) recipients with significant renal dysfunction posttransplant priority for subsequent kidney transplantation (KT). This study was undertaken to evaluate early outcomes under this policy. METHODS Adults undergoing LTA after implementation of the safety net policy and were subsequently listed for KT between 60 and 365 days after liver transplantation contained in United Network for Organ Sharing data were examined. Outcomes of interest were receipt of a kidney transplant and postliver transplant survival. Safety net patients were compared with LTA recipients not subsequently listed for KT as well as to patients listed for simultaneous liver-kidney (SLK) transplant yet underwent LTA and were not subsequently listed for KT. RESULTS There were 100 patients listed for safety net KT versus 9458 patients undergoing LTA without subsequent KT listing. The cumulative incidence of KT following listing was 32.5% at 180 days. The safety net patients had similar 1-year unadjusted patient survival (96.4% versus 93.4%; P = 0.234) but superior adjusted survival (hazard ratio0.133, 0.3570.960; P = 0.041) versus LTA recipients not subsequently listed for KT. Safety net patients had superior 1-year unadjusted (96.4% versus 75.0%; P < 0.001) and adjusted (hazard ratio0.039, 0.1260.406; P < 0.001) survival versus SLK listed patients undergoing LTA without subsequent KT listing. CONCLUSIONS The safety net appears to provide rapid access to KT with good early survival for those able to take advantage of it. Survival of patients unable to qualify for KT listing after LTA needs to be better understood before further limitation of SLK, however.
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Affiliation(s)
- Robert M Cannon
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - David S Goldberg
- Division of Hepatology, Department of Medicine, University of Miami, Coral Gables, FL
| | - Devin E Eckhoff
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Douglas J Anderson
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Babak J Orandi
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E Locke
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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20
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Morelli MC, Rendina M, La Manna G, Alessandria C, Pasulo L, Lenci I, Bhoori S, Messa P, Biancone L, Gesualdo L, Russo FP, Petta S, Burra P. Position paper on liver and kidney diseases from the Italian Association for the Study of Liver (AISF), in collaboration with the Italian Society of Nephrology (SIN). Dig Liver Dis 2021; 53 Suppl 2:S49-S86. [PMID: 34074490 DOI: 10.1016/j.dld.2021.03.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/31/2021] [Accepted: 03/31/2021] [Indexed: 02/07/2023]
Abstract
Liver and kidney are strictly connected in a reciprocal manner, in both the physiological and pathological condition. The Italian Association for the Study of Liver, in collaboration with the Italian Society of Nephrology, with this position paper aims to provide an up-to-date overview on the principal relationships between these two important organs. A panel of well-recognized international expert hepatologists and nephrologists identified five relevant topics: 1) The diagnosis of kidney damage in patients with chronic liver disease; 2) Acute kidney injury in liver cirrhosis; 3) Association between chronic liver disease and chronic kidney disease; 4) Kidney damage according to different etiology of liver disease; 5) Polycystic kidney and liver disease. The discussion process started with a review of the literature relating to each of the five major topics and clinical questions and related statements were subsequently formulated. The quality of evidence and strength of recommendations were graded according to the GRADE system. The statements presented here highlight the importance of strong collaboration between hepatologists and nephrologists for the management of critically ill patients, such as those with combined liver and kidney impairment.
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Affiliation(s)
- Maria Cristina Morelli
- Internal Medicine Unit for the treatment of Severe Organ Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy, Via Albertoni 15, 40138, Bologna, Italy
| | - Maria Rendina
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Policlinic Hospital, Piazza G. Cesare 11, 70124, Bari, Italy
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Torino, Corso Bramante 88, 10126, Torino, Italy
| | - Luisa Pasulo
- Gastroenterology and Transplant Hepatology, "Papa Giovanni XXIII" Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Ilaria Lenci
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome Viale Oxford 81, 00133, Rome, Italy
| | - Sherrie Bhoori
- Hepatology and Hepato-Pancreatic-Biliary Surgery and Liver Transplantation, Fondazione IRCCS, Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133, Milan, Italy
| | - Piergiorgio Messa
- Unit of Nephrology, Università degli Studi di Milano, Via Commenda 15, 20122, Milano, Italy; Nephrology, Dialysis and Renal Transplant Unit-Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Commenda 15, 20122 Milano, Italy
| | - Luigi Biancone
- Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città Della Salute e della Scienza Hospital, University of Turin, Corso Bramante, 88-10126, Turin, Italy
| | - Loreto Gesualdo
- Nephrology Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, Università degli Studi di Bari "Aldo Moro", Piazza G. Cesare 11, 70124, Bari, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, PROMISE, University of Palermo, Piazza delle Cliniche, 2 90127, Palermo, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy.
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21
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Westphal SG, Langewisch ED, Robinson AM, Wilk AR, Dong JJ, Plumb TJ, Mullane R, Merani S, Hoffman AL, Maskin A, Miles CD. The impact of multi-organ transplant allocation priority on waitlisted kidney transplant candidates. Am J Transplant 2021; 21:2161-2174. [PMID: 33140571 DOI: 10.1111/ajt.16390] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 01/25/2023]
Abstract
Kidney-alone transplant (KAT) candidates may be disadvantaged by the allocation priority given to multi-organ transplant (MOT) candidates. This study identified potential KAT candidates not receiving a given kidney offer due to its allocation for MOT. Using the Organ Procurement and Transplant Network (OPTN) database, we identified deceased donors from 2002 to 2017 who had one kidney allocated for MOT and the other kidney allocated for KAT or simultaneous pancreas-kidney transplant (SPK) (n = 7,378). Potential transplant recipient data were used to identify the "next-sequential KAT candidate" who would have received a given kidney offer had it not been allocated to a higher prioritized MOT candidate. In this analysis, next-sequential KAT candidates were younger (p < .001), more likely to be racial/ethnic minorities (p < .001), and more highly sensitized than MOT recipients (p < .001). A total of 2,113 (28.6%) next-sequential KAT candidates subsequently either died or were removed from the waiting list without receiving a transplant. In a multivariable model, despite adjacent position on the kidney match-run, mortality risk was significantly higher for next-sequential KAT candidates compared to KAT/SPK recipients (hazard ratio 1.55, 95% confidence interval 1.44, 1.66). These results highlight implications of MOT allocation prioritization, and potential consequences to KAT candidates prioritized below MOT candidates.
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Affiliation(s)
- Scott G Westphal
- Department of Internal Medicine, Nephrology Division, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Eric D Langewisch
- Department of Internal Medicine, Nephrology Division, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Amanda M Robinson
- Research Department, United Network of Organ Sharing, Richmond, Virginia, USA
| | - Amber R Wilk
- Research Department, United Network of Organ Sharing, Richmond, Virginia, USA
| | - Jianghu J Dong
- Department of Internal Medicine, Nephrology Division, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Department of Biostatistics, University of Nebraska Medical Center, College of Public Health, Omaha, Nebraska, USA
| | - Troy J Plumb
- Department of Internal Medicine, Nephrology Division, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Ryan Mullane
- Department of Internal Medicine, Nephrology Division, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Shaheed Merani
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Arika L Hoffman
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Alexander Maskin
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Clifford D Miles
- Department of Internal Medicine, Nephrology Division, University of Nebraska Medical Center, Omaha, Nebraska, USA
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22
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Altshuler PJ, Shah AP, Frank AM, Glorioso J, Dang H, Shaheen O, Patel K, Ramirez CB, Maley WR, Bodzin AS. Simultaneous liver kidney allocation policy and the Safety Net: an early examination of utilization and outcomes in the United States. Transpl Int 2021; 34:1052-1064. [PMID: 33884677 DOI: 10.1111/tri.13891] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 04/12/2021] [Indexed: 01/31/2023]
Abstract
Rates of simultaneous liver kidney (SLK) transplantation in the United States have progressively risen. On 8/10/17, the Organ Procurement and Transplantation Network implemented a policy defining criteria for SLK, with a "Safety Net" to prioritize kidney allocation to liver recipients with ongoing renal failure. We performed a retrospective review of the United Network for Organ Sharing (UNOS) database to evaluate policy impact on SLK, kidney after liver (KAL) and kidney transplant alone (KTA). Rates and outcomes of SLK and KAL transplants were compared, as was utilization of high-quality kidney allografts with Kidney Donor Profile Indices (KDPI) <35%. Here, SLK transplants comprised 9.0% and 4.5% of total postpolicy liver and kidney transplants compared to 10.2% and 5.5% prior. Policy enactment did not affect 1-year graft or patient survival for SLK and KAL populations. Less postpolicy SLK transplants utilized high-quality kidney allografts; in all transplant settings, outcomes using high-quality grafts remained stable. These findings suggest that policy implementation has reduced kidney allograft use in SLK transplantation, although both SLK and KAL rates have recently increased. Despite decreased high-quality kidney allograft use, SLK and KAL outcomes have remained stable. Additional studies and long-term follow-up will ensure optimal organ access and sharing.
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Affiliation(s)
- Peter J Altshuler
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ashesh P Shah
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam M Frank
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jaime Glorioso
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Hien Dang
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Osama Shaheen
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Keyur Patel
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Carlo B Ramirez
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Warren R Maley
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam S Bodzin
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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23
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Cullaro G, Verna EC, Emond JC, Orandi BJ, Mohan S, Lai JC. Early Kidney Allograft Failure After Simultaneous Liver-kidney Transplantation: Evidence for Utilization of the Safety Net? Transplantation 2021; 105:816-823. [PMID: 32413016 PMCID: PMC7971118 DOI: 10.1097/tp.0000000000003310] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND With the implementation of the "Safety Net," we aimed to determine the impact of simultaneous liver-kidney transplantation (SLKT), as compared to kidney transplant after liver transplant (KALT), on kidney allograft failure (KF). METHODS An analysis of the UNOS database for all adult patients who received either an SLKT or KALT from 2002 to 2017. The outcomes were 90-day KF and 1-year KF (as reported to UNOS, at 90- and 365-day postkidney transplant, respectively). We compared the following groups of patients: SLKT <25 (SLKT with final model for end-stage liver disease [MELD] <25), SLKT25/35 (MELD ≥25/<35), and SLKT35 (MELD ≥35) to KALT. RESULTS Of the 6276 patients, there were 1481 KALT, 1579 SLKT <25, 1832 SLKT25/35, and 1384 SLKT ≥35. The proportion of patients with 90-day and 1-year KF increased significantly among the KALT, SLKT <25, SLKT25/35, and SLKT ≥35 groups (P < 0.001; test for trend): 90-day KF: 3.3% versus 5.5% versus 7.3% versus 9.3% and 1-year KF: 5.1% versus 9.4% versus 12.3% versus 14.7%. After adjustment and compared with KALT, beginning at an MELD ≥25 those undergoing SLKT had significantly higher risk of 90-day and 1-year KF: 90-day KF: SLKT25/35: hazard ratio, 1.6(1.0-2.3); SLKT ≥35: 2.1(1.3-3.3); 1-year KF: SLKT25/35: hazard ratio, 1.7(1.2-2.4); SLKT ≥35: 2.1(1.5-3.0). CONCLUSIONS As compared to KALT recipients, SLKT recipients with an MELD ≥25 had significantly higher risk of early KF. Given the now well-established "Safety Net," KALT may serve as an opportunity to improve kidney outcomes in patients with an MELD ≥25.
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Affiliation(s)
- Giuseppe Cullaro
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Jean C. Emond
- Department of Surgery, Division of Transplantation, Vagelos College of Physicians & Surgeons, New York, New York
| | - Babak J. Orandi
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, CA, USA
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24
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Bari K, Sharma P. Optimizing the Selection of Patients for Simultaneous Liver-Kidney Transplant. Clin Liver Dis 2021; 25:89-102. [PMID: 33978585 DOI: 10.1016/j.cld.2020.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Simultaneous liver-kidney transplantation has increased significantly in the Model for End Stage Liver Disease era. The transplantation policy has evolved significantly since the implementation of allocation based on the Model for End Stage Liver Disease. Current policy takes into account the medical eligibility criteria for simultaneous liver-kidney transplantation listing. It also provides a safety net option and prioritizes kidney transplant after liver transplant recipients who are unlikely to recover their renal function within 60 to 365 days after liver transplant alone. This review seeks to understand the underlying challenges in carefully selecting the candidates while optimizing the patient selection.
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Affiliation(s)
- Khurram Bari
- Division of Gastroenterology and Hepatology, University of Cincinnati, 231 Albert Sabin Way, ML 0595, MSB 7259, Cincinnati, OH 45267, USA
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, 3912 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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25
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Zhang PP, She XG, Cheng K, Liu H, Niu Y, Ming YZ. Liver transplantation for liver failure in kidney transplantation recipients with hepatitis B virus infection. Hepatobiliary Pancreat Dis Int 2021; 20:94-98. [PMID: 33067141 DOI: 10.1016/j.hbpd.2020.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 09/14/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Peng-Peng Zhang
- Transplantation Center, Third Xiangya Hospital, Central South University, Changsha 410013, China; Engineering & Technology Research Center for Transplantation Medicine of National Ministry of Health, Changsha 410013, China
| | - Xing-Guo She
- Transplantation Center, Third Xiangya Hospital, Central South University, Changsha 410013, China; Engineering & Technology Research Center for Transplantation Medicine of National Ministry of Health, Changsha 410013, China
| | - Ke Cheng
- Transplantation Center, Third Xiangya Hospital, Central South University, Changsha 410013, China; Engineering & Technology Research Center for Transplantation Medicine of National Ministry of Health, Changsha 410013, China
| | - Hong Liu
- Transplantation Center, Third Xiangya Hospital, Central South University, Changsha 410013, China; Engineering & Technology Research Center for Transplantation Medicine of National Ministry of Health, Changsha 410013, China
| | - Ying Niu
- Transplantation Center, Third Xiangya Hospital, Central South University, Changsha 410013, China; Engineering & Technology Research Center for Transplantation Medicine of National Ministry of Health, Changsha 410013, China
| | - Ying-Zi Ming
- Transplantation Center, Third Xiangya Hospital, Central South University, Changsha 410013, China; Engineering & Technology Research Center for Transplantation Medicine of National Ministry of Health, Changsha 410013, China.
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Choi G. CON: Liver Transplant Alone. Clin Liver Dis (Hoboken) 2021; 16:272-275. [PMID: 33489101 PMCID: PMC7805303 DOI: 10.1002/cld.979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 04/27/2020] [Accepted: 05/14/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Gina Choi
- Department of Medicine and SurgeryUniversity of California, Los Angeles, David Geffen School of MedicineLos AngelesCA
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New OPTN Simultaneous Liver-Kidney Transplant (SLKT) Policy Improves Racial and Ethnic Disparities. J Clin Med 2020; 9:jcm9123901. [PMID: 33271833 PMCID: PMC7760665 DOI: 10.3390/jcm9123901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 12/19/2022] Open
Abstract
(1) Background: On 10 August 2017, the Organ Procurement and Transplantation Network (OPTN) adopted standardized eligibility criteria to properly determine which transplant candidates should undergo Simultaneous Liver-Kidney Transplant (SLKT). Racial and ethnic disparities have not been examined after 2017. Therefore, using the United Network for Organ Sharing (UNOS), we aim to evaluate post-graft survival outcomes among Caucasians, African Americans, and Hispanics. (2) Methods: Kaplan-Meier curves and Cox regression models are used to compare post-transplant graft survival for Caucasians, African Americans (AAs), and Hispanics. Competing risk analysis is used to evaluate the cumulative incidence of death or re-transplantation with re-transplantation and death as competing risks. (3) Results: On multivariate Cox regression analysis, no differences in graft survival are found in AA (hazard ratio (HR): 1.30; 95% CI: 0.74-2.29 p = 0.354) or Hispanics (HR: 1.18; 95% CI: 0.70-2 p = 0.520) compared to Caucasians after 2017. On competing risk analysis of the risk of death with re-transplantation as a competing risk, no difference is found between ethnic minorities after 2017. There is a similar finding from competing risk analysis of the risk of re-transplantation with death as a competing risk. (4) Conclusion: After introducing standardized eligibility criteria for SLKT allocation, the post-graft survival outcomes remain similar between the different racial and ethnic groups, displaying the benefits of adopting such policy in 2017.
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Yazawa M, Cseprekal O, Helmick RA, Talwar M, Balaraman V, Podila PSB, Fossey S, Satapathy SK, Eason JD, Molnar MZ. Association between longer hospitalization and development of de novo donor specific antibodies in simultaneous liver-kidney transplant recipients. Ren Fail 2020; 42:40-47. [PMID: 31875761 PMCID: PMC6968335 DOI: 10.1080/0886022x.2019.1705338] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/03/2019] [Accepted: 12/04/2019] [Indexed: 12/17/2022] Open
Abstract
Background: De novo Donor Specific Antibodies (DSA) are considered as a risk factor for the kidney allograft outcomes in recipients after simultaneous liver-kidney transplantation (SLKT). We hypothesized that length of hospital stay (LOS) might be associated with de novo DSA development of due to the increased likelihood of receiving blood transfusions with reduced immunosuppressive regimens.Methods: This study is a single-center, retrospective cohort study consisting of 85 recipients who underwent SLKT from 2009 to 2018 in our hospital. We divided the patients into two groups according to LOS [long hospital stay (L) group (LOS >14 days) and short hospital stay (S) group (LOS ≤14 days)]. Propensity score (PS) has been created using logistic regression to predict LOS greater than median of 14 days. The association between the presence of de novo DSA and LOS was assessed by logistic regression models adjusted for PS.Results: The mean age at transplantation of the entire cohort was 55.5 ± 10.1 years. Sixty percent of the recipients were male and Caucasian. Median LOS in (L) group was three-fold longer than (S) group [L: median 30 days (IQR: 21-52), S: median 8.5 days (IQR: 7-11)]. Eight patients developed de novo DSA after SLKT (9.4%), all of them were in (L) group. Longer LOS was significantly associated with higher risk of development of de novo DSA in unadjusted (OR+ each 5 days: 1.09, 95% CI:1.02-1.16) and PS adjusted (OR+ each 5 days: 1.11, 95% CI:1.02-1.21) analysis.Conclusion: Longer hospitalization is significantly associated with the development of de novo DSA in SLKT.
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Affiliation(s)
- Masahiko Yazawa
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Orsolya Cseprekal
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Ryan A. Helmick
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Manish Talwar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Vasanthi Balaraman
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Pradeep S. B. Podila
- Faith and Health Division, Methodist Le Bonheur Healthcare, Memphis, TN, USA
- Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, TN, USA
| | | | - Sanjaya K. Satapathy
- Sandra Atlas Bass Center for Liver Diseases and Transplantation, Department of Medicine, Northshore University Hospital/Northwell Health, Manhasset, NY, USA
| | - James D. Eason
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Miklos Z. Molnar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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Abstract
BACKGROUND Delayed graft function (DGF) is associated with inferior posttransplant outcomes in kidney transplantation. Given these adverse outcomes, we sought to determine the incidence, unique risk factors, and posttransplant outcomes for simultaneous liver kidney (SLK) transplant recipients developing DGF. METHODS We studied 6214 adult SLK recipients from March 2002 to February 2017 using the Scientific Registry of Transplant Recipients. We determined associations between risk factors and DGF using Poisson multivariate regression and between DGF and graft failure and mortality using Cox proportional hazard analysis. RESULTS The overall rate of DGF was 21.8%. Risk factors for DGF in the hepatitis C virus (HCV)-negative recipient population included pretransplant dialysis (adjusted incident rate ratio [aIRR] 3.26, P = 0.004), donor body mass index (aIRR 1.25 per 5 kg/m, P = 0.01), and transplantation with a donation after circulatory death (aIRR 5.38, P = 0.001) or imported donor organ (regional share aIRR 1.69, P = 0.03; national share aIRR 4.82, P < 0.001). DGF was associated with a 2.6-fold increase in kidney graft failure (adjusted hazard ratio [aHR] 2.63, P < 0.001), 1.6-fold increase in liver graft failure (aHR 1.62, P < 0.001), and 1.6-fold increase in mortality (aHR 1.62, P < 0.001). CONCLUSIONS In HCV-negative SLK recipients, recipient pretransplant dialysis and components of kidney graft quality comprise significant risk factors for DGF. Regardless of HCV status, DGF is associated with inferior posttransplant outcomes. Understanding these risk factors during clinical decision-making may improve prevention of DGF and may represent an opportunity to improve posttransplant outcomes.
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Trends and Outcomes in Simultaneous Liver and Kidney Transplantation in Australia and New Zealand. Transplant Proc 2020; 53:136-140. [PMID: 32933766 DOI: 10.1016/j.transproceed.2020.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/27/2020] [Accepted: 08/08/2020] [Indexed: 11/20/2022]
Abstract
AIM Rates of simultaneous liver and kidney transplantation (SLKT) have increased, but indications for SLKT remain poorly defined. Additional data are needed to determine which patients benefit from SLKT to best direct use of scarce donor kidneys. METHODS Data were extracted from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) database for all SLKT performed until the end of 2017. Patients were divided by pretransplant dialysis status into no dialysis before SLKT (preemptive kidney transplant) and any dialysis before SLKT (nonpreemptive). Baseline characteristics and outcomes were compared. RESULTS Between 1989 and 2017, inclusive, 84 SLKT procedures were performed in Australia, of which 24% were preemptive. Preemptive and nonpreemptive SLKT recipients did not significantly differ in age (P = .267), sex (P = .526), or ethnicity (P = .870). Over a median follow-up time of 4.5 years, preemptively transplanted patients had a statistically equivalent risk of kidney graft failure (hazard ratio (HR) 1.83, 95% confidence interval [CI]: 0.36-12.86, P = .474) and all-cause mortality (HR 1.69, 95% CI: 0.51-5.6, P = .226) compared to nonpreemptive patients. Overall, 1- and 5-year survival rates for all SLKTs were 92% (95% CI: 86-96) and 60% (95% CI: 45-75), respectively. CONCLUSION Kidney graft and overall patient survival were similar between patients with preemptive kidney transplant and those who were dialysis dependent.
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Weeks SR, Luo X, Toman L, Gurakar AO, Naqvi FF, Alqahtani SA, Philosophe B, Cameron AM, Desai NM, Ottmann SE, Segev DL, Garonzik-Wang J. Steroid-sparing maintenance immunosuppression is safe and effective after simultaneous liver-kidney transplantation. Clin Transplant 2020; 34:e14036. [PMID: 32652700 DOI: 10.1111/ctr.14036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/23/2020] [Accepted: 06/28/2020] [Indexed: 12/25/2022]
Abstract
Optimization of maintenance immunosuppression (mIS) regimens in the transplant recipient requires a balance between sufficient potency to prevent rejection and avoidance of excessive immunosuppression to prevent toxicities and complications. The optimal regimen after simultaneous liver-kidney (SLK) transplantation remains unclear, but small single-center reports have shown success with steroid-sparing regimens. We studied 4184 adult SLK recipients using the Scientific Registry of Transplant Recipients, from March 1, 2002, to February 28, 2017, on tacrolimus-based regimens at 1 year post-transplant. We determined the association between mIS regimen and mortality and graft failure using Cox proportional hazard models. The use of steroid-sparing regimens increased post-transplant, from 16.1% at discharge to 88.0% at 5 years. Using multi-level logistic regression modeling, we found center-level variation to be the major contributor to choice of mIS regimen (ICC 44.5%; 95% CI: 36.2%-53.0%). In multivariate analysis, use of a steroid-sparing regimen at 1 year was associated with a 21% decreased risk of mortality compared to steroid-containing regimens (aHR 0.79, P = .01) and 20% decreased risk of liver graft failure (aHR 0.80, P = .01), without differences in kidney graft loss risk (aHR 0.92, P = .6). Among SLK recipients, the use of a steroid-sparing regimen appears to be safe and effective without adverse effects on patient or graft survival.
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Affiliation(s)
- Sharon R Weeks
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Xun Luo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lindsey Toman
- Department of Pharmacy, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ahmet O Gurakar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fizza F Naqvi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Saleh A Alqahtani
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Benjamin Philosophe
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew M Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Niraj M Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shane E Ottmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA.,Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
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Difference in Survival in Early Kidney after Liver Transplantation Compared with Simultaneous Liver-Kidney Transplantation: Evaluating the Potential of the “Safety Net”. J Am Coll Surg 2020; 230:463-473. [DOI: 10.1016/j.jamcollsurg.2019.12.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/16/2019] [Indexed: 11/20/2022]
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Changes in Simultaneous Liver-kidney Transplant Allocation Policy May Impact Postliver Transplant Outcomes. Transplantation 2019; 103:959-964. [PMID: 30086097 DOI: 10.1097/tp.0000000000002403] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Previous simultaneous liver-kidney (SLK) transplant allocation was based on serum creatinine, a metric that disadvantaged women relative to men. A recent SLK transplant policy change uses estimated glomerular filtration rate (eGFR), which accounts for sex-based differences in creatinine. METHODS To understand the impact of this new policy, we analyzed nonstatus 1 adults listed for liver transplantation (LT) from May 2007 to July 2014, excluding those with exceptions. We defined patients who met the new SLK policy as having an eGFR <60 mL/min for 90 days, with a final eGFR <30 mL/min. RESULTS Of 40979 candidates, 1683 would have met only the new criteria (N-SLK), 2452 would have met only the old criteria (O-SLK), and 1878 would have met both criteria (B-SLK). Compared to those in the B-SLK or O-SLK groups, those in the N-SLK group were significantly more likely to be female (52% versus 36% versus 39%, P < 0.001). Cox-regression analysis demonstrated that in adjusted analysis those in the N-SLK group were significantly less likely to die postliver transplant (hazard ratio [HR], 0.0; P < 0.001). Further, in Cox regression subgroup analyses, both in women (HR 0.04; P < 0.001) and in men (HR, 0.02, P < 0.001) those in the N-SLK group who underwent liver transplant were significantly less likely to die postliver transplant, even after adjustment for confounders. CONCLUSIONS We anticipate that implementation of the new SLK policy will increase the proportion of women and decrease the proportion of men who are listed for SLK but may not improve posttransplant survival. Our data highlight the need for monitoring of SLK outcomes after implementation of the new policy.
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Outcomes of Liver Transplantation in Patients on Renal Replacement Therapy: Considerations for Simultaneous Liver Kidney Transplantation Versus Safety Net. Transplant Direct 2019; 5:e490. [PMID: 31723585 PMCID: PMC6791601 DOI: 10.1097/txd.0000000000000935] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 08/04/2019] [Indexed: 12/26/2022] Open
Abstract
As the liver transplant (LT) waiting list continues to outpace organ availability, many patients require renal replacement therapy (RRT) before LT. It is unclear which patients will benefit from simultaneous liver kidney (SLK) transplant as opposed to awaiting a Safety Net kidney transplant (KT) post-LT. Methods In this study, a retrospective analysis of the United Network for Organ Sharing dataset was performed to identify risk factors associated with poor outcome for patients on RRT before LT who were listed for SLK and received either SLK vs LT alone (LTA). Results Between January 2003 and December 2016, 8971 adult LT recipients were on RRT at the time of LT. 5359 were listed for and received LTA (Group 1). Of 3612 patients listed for SLK, 3414 (38.1%) received SLK (Group 2) and 198 (2.2%) received LTA (Group 3). Overall, Group 3 had lower graft and patient survival post-LT when compared with Groups 1 and 2 (P < 0.001). Serum creatinine at 1 year post-LT and cumulative incidence for KT at 3 years post-LT were higher for Group 3 (P < 0.001). On multivariate analysis, pre-LT diabetes (P = 0.002), Model of End-Stage Liver Disease score (P = 0.01), and donor kidney donor profile index (P = 0.025) were significant in Group 2. Recipient age >60 (P < 0.001) and RRT pre-LT (>90 days; P = 0.001) were associated with lower patient survival in Group 3. Conclusions Among LT recipients on RRT before LT who were listed for SLK, RRT >90 days, and age >60 were associated with poor outcome following LTA. This suggests that programs should carefully weigh the decision to proceed with LTA vs waiting for SLK in this patient population. Future access to Safety Net KT will be an important consideration for these patients moving forward.
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Sharma P. Liver-Kidney: Indications, Patient Selection, and Allocation Policy. Clin Liver Dis (Hoboken) 2019; 13:165-169. [PMID: 31316763 PMCID: PMC6605734 DOI: 10.1002/cld.787] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 11/24/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Pratima Sharma
- Department of Gastroenterology and HepatologyUniversity of Michigan Institute of Healthcare Policy & InnovationAnn ArborMI
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36
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Cannon RM, Davis EG, Jones CM. A Tale of Two Kidneys: Differences in Graft Survival for Kidneys Allocated to Simultaneous Liver Kidney Transplant Compared with Contralateral Kidney from the Same Donor. J Am Coll Surg 2019; 229:7-17. [DOI: 10.1016/j.jamcollsurg.2019.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/28/2019] [Accepted: 04/15/2019] [Indexed: 12/21/2022]
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Lum EL, Cárdenas A, Martin P, Bunnapradist S. Current Status of Simultaneous Liver-Kidney Transplantation in the United States. Liver Transpl 2019; 25:797-806. [PMID: 30861294 DOI: 10.1002/lt.25444] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 03/01/2019] [Indexed: 02/07/2023]
Abstract
On August 10, 2017, a formal policy was enacted in the United States that defined listing criteria for simultaneous liver-kidney transplantation and priority for patients who received a liver transplantation (LT) and subsequently developed significant kidney disease after LT. This article reviews and summarizes the rationale for such policies, the policies themselves, and the potential impact on LT candidates.
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Affiliation(s)
- Erik L Lum
- Division of Nephrology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA
| | - Andrés Cárdenas
- Institute of Digestive Diseases and Metabolism, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Paul Martin
- Division of Gastroenterology and Hepatology, Miller School of Medicine, University of Miami, Miami, FL
| | - Suphamai Bunnapradist
- Division of Nephrology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA
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Tinti F, Mitterhofer AP, Umbro I, Nightingale P, Inston N, Ghallab M, Ferguson J, Mirza DF, Ball S, Lipkin G, Muiesan P, Perera MTPR. Combined liver-kidney transplantation versus liver transplant alone based on KDIGO stratification of estimated glomerular filtration rate: data from the United Kingdom Transplant registry - a retrospective cohort study. Transpl Int 2019; 32:918-932. [PMID: 30793378 DOI: 10.1111/tri.13413] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 10/29/2018] [Accepted: 02/18/2019] [Indexed: 12/22/2022]
Abstract
Patient selection for combined liver-kidney transplantation (CLKT) is a current issue on the background of organ shortage. This study aimed to compare outcomes and post-transplant renal function for patients receiving CLKT and liver transplantation alone (LTA) based on native renal function using estimated glomerular filtration rate (eGFR) stratification. Using the UK National transplant database (NHSBT) 6035 patients receiving a LTA (N = 5912; 98%) or CLKT (N = 123; 2%) [2001-2013] were analysed, and stratified by KDIGO stages of eGFR at transplant (eGFR group-strata). There was no difference in patient/graft survival between LTA and CLKT in eGFR group-strata (P > 0.05). Of 377 patients undergoing renal replacement therapy (RRT) at time of transplantation, 305 (81%) and 72 (19%) patients received LTA and CLKT respectively. A significantly greater proportion of CLKT patients had severe end-stage renal disease (eGFR < 30 ml/min/1.73 m2 ) at 1 year post-transplant compared to LTA (9.5% vs. 5.7%, P = 0.001). Patient and graft survival benefit for patients on RRT at transplantation was favouring CLKT versus LTA (P = 0.038 and P = 0.018, respectively) but the renal function of the long-term survivors was not superior following CLKT. The data does not support CLKT approach based on eGFR alone, and the advantage of CLKT appear to benefit only those who are on established RRT at the time of transplant.
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Affiliation(s)
- Francesca Tinti
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Nephrology Unit, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Anna Paola Mitterhofer
- Nephrology Unit, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Ilaria Umbro
- Nephrology Unit, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Peter Nightingale
- Medical Statistics Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Nicholas Inston
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Mohammed Ghallab
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - James Ferguson
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Darius F Mirza
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Simon Ball
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Graham Lipkin
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Cannon RM, Jones CM, Davis EG, Eckhoff DE. Effect of Renal Diagnosis on Survival in Simultaneous Liver-Kidney Transplantation. J Am Coll Surg 2018; 228:536-544.e3. [PMID: 30586642 DOI: 10.1016/j.jamcollsurg.2018.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Simultaneous liver-kidney transplantation is lifesaving, however, the utility of allocating 2 organs to a single recipient remains controversial, particularly in the face of potentially inferior survival. This study aims to determine the effect of renal indication for transplantation on simultaneous liver-kidney transplantation outcomes. METHODS All adult recipients of combined whole liver-kidney transplants in the United Network for Organ Sharing database from 2003 to 2016 with a renal diagnosis of hypertension (HTN), diabetes mellitus (DM), acute tubular necrosis (ATN), or hepatorenal syndrome (HRS) were examined. Comparisons were made between the HTN/DM group and the ATN/HRS group using standard statistical methods. RESULTS There were 1,204 patients in the HRS/ATN group vs 1,272 patients in the HTN/DM group. The HTN/DM patients were slightly older (58.1 vs 56.4 years; p < 0.001), more likely to have liver disease due to chronic viral hepatitis (33.2% vs 21.5%; p < 0.001), and less acutely ill (mean Model for End-Stage Liver Disease score of 27.2 vs 33.1; p < 0.001) than their HRS/ATN counterparts. The prevalence of nonalcoholic steatohepatitis was 16.8% in both groups. Donor demographics were similar in both groups, although HTN/DM patients were more likely to have a local (81.6% vs 67.7%; p < 0.001) rather than regional donor. Patient survival rates at 1, 3, and 5 years were significantly lower in the HTN/DM group (87.4%, 78.2%, and 71.2% vs 90.7%, 84.1%, and 76.6%, respectively). Median survival was 118 months for the HTN/DM group vs 139.7 months for the HRS/ATN (p < 0.001). The HTN/DM patients were at significantly higher risk of death (hazard ratio 1.533; p < 0.001), liver graft loss (hazard ratio 1.611; p < 0.001), and renal graft loss (hazard ratio 1.592; p < 0.001) than ATN/HRS patients on multivariable analysis. CONCLUSIONS Despite a lower acuity of illness, HTN/DM patients have inferior survival after simultaneous liver-kidney transplantation than those with ATN/HRS. This should be considered in risk adjustment and allocation schemes.
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Affiliation(s)
- Robert M Cannon
- Hiram C Polk Jr, MD Department of Surgery, Division of Transplantation, University of Louisville, Louisville, KY.
| | - Christopher M Jones
- Hiram C Polk Jr, MD Department of Surgery, Division of Transplantation, University of Louisville, Louisville, KY
| | - Eric G Davis
- Hiram C Polk Jr, MD Department of Surgery, Division of Transplantation, University of Louisville, Louisville, KY
| | - Devin E Eckhoff
- Department of Surgery, Division of Abdominal Transplantation, University of Alabama at Birmingham, Birmingham, AL
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Chauhan K, Azzi Y, Faddoul G, Liriano‐Ward L, Chang P, Nadkarni G, Delaney V, Ames S, Debnath N, Singh N, Sehgal V, Di Boccardo G, Garzon F, Nair V, Kent R, Lerner S, Coca S, Shapiro R, Florman S, Schiano T, Menon MC. Pre‐liver transplant renal dysfunction and association with post‐transplant end‐stage renal disease: A single‐center examination of updated UNOS recommendations. Clin Transplant 2018; 32:e13428. [DOI: 10.1111/ctr.13428] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 08/30/2018] [Accepted: 10/04/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Kinsuk Chauhan
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Yorg Azzi
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Geovani Faddoul
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Luz Liriano‐Ward
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Paul Chang
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Girish Nadkarni
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Veronica Delaney
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Scott Ames
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Neha Debnath
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Nandita Singh
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Vinita Sehgal
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Graciela Di Boccardo
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Felipe Garzon
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Vinay Nair
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Rebecca Kent
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Susan Lerner
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Steven Coca
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Ron Shapiro
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Sander Florman
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Thomas Schiano
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Madhav C. Menon
- Recanati Miller Transplant Institute Icahn School of Medicine at Mount Sinai New York City New York
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Baseline and Center-Level Variation in Simultaneous Liver-Kidney Listing in the United States. Transplantation 2018; 102:609-615. [PMID: 29077659 DOI: 10.1097/tp.0000000000001984] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The Organ Procurement and Transplantation Network has implemented medical criteria to determine which candidates are most appropriate for simultaneous liver-kidney (SLK) transplantation in comparison to liver-alone transplantation. We investigated prepolicy center-level variation among SLK listing practice, in light of such criteria. METHODS We identified 4736 SLK-eligible candidates after Share-35 in the United States. We calculated the proportion of candidates at each center who were listed for SLK transplantation within 6 months of eligibility. Multilevel logistic regression and parametric survival model was used to estimate the center-specific probability of SLK listing, adjusting for patient and center-level characteristics. RESULTS Among 4736 SLK-eligible candidates, 64.8% were listed for SLK within 6 months of eligibility. However, the percentage of SLK listing ranged from 0% to 100% across centers. African American race, male sex, transplant history, diabetes, and hypertension were associated with a higher likelihood of SLK listing. Conversely, older age was associated with a lower likelihood of SLK listing. After adjusting for candidate characteristics, the percentage of SLK listing still ranged from 3.8% to 80.2% across centers; this wide variation persisted even after further adjusting for center-level characteristics. CONCLUSIONS There was significant prepolicy center-level variation in SLK listing for SLK-eligible candidates. Implementation of standardized SLK listing practices may reduce center-level variation and equalize access for SLK candidates across the United States.
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Shekhtman G, Huang E, Danovitch GM, Martin P, Bunnapradist S. Combined Dual-Kidney Liver Transplantation in the United States: A Review of United Network for Organ Sharing/Organ Procurement and Transplantation Network Data Between 2002 and 2012. Liver Transpl 2018; 24:1570-1577. [PMID: 29493877 DOI: 10.1002/lt.25045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 08/22/2016] [Accepted: 01/31/2018] [Indexed: 02/07/2023]
Abstract
In kidney-alone recipients, dual-kidney transplantation using "higher-risk" donor organs has shown outcomes comparable to those of single-kidney transplantation using extended criteria donor (ECD) organs. To investigate the feasibility of a similar approach with combined kidney-liver transplantation, we identified 22 dual-kidney liver transplantations (DKLTs) and 3044 single-kidney liver transplantations (SKLTs) performed in the United States between 2002 and 2012 using United Network for Organ Sharing/Organ Procurement and Transplantation Network registry data. We compared donor/recipient characteristics as well as graft/recipient survival between DKLT recipients and SKLT recipients of "higher-risk" kidneys (ECD and high kidney donor profile index [KDPI; >85%] donors). Despite having overall similar donor and recipient characteristics compared with both "higher-risk" donor groups, recipient survival in the DKLT group at 36 months was markedly inferior at 40.9% (compared with 67.5% for ECD SKLT recipients and 64.5% for high-KDPI SKLT recipients); nondeath-censored graft survival did not differ. Death was the most common cause of graft loss in all groups. Contrary to dual-kidney transplantation data in kidney-alone recipients, DKLT recipients in our study had inferior survival when compared with SKLT recipients of "higher-risk" donor kidneys. These findings would suggest that dual kidney-liver transplantation has an uncertain role as a strategy to expand the existing kidney donor pool in combined transplantation.
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Affiliation(s)
- Grigoriy Shekhtman
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | | | - Gabriel M Danovitch
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Paul Martin
- Department of Medicine, University of Miami Miller School of Medicine and the Miami Veterans Administration Hospital, Miami, FL
| | - Suphamai Bunnapradist
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
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Hussain SM, Sureshkumar KK. Refining the Role of Simultaneous Liver Kidney Transplantation. J Clin Transl Hepatol 2018; 6:289-295. [PMID: 30271741 PMCID: PMC6160299 DOI: 10.14218/jcth.2017.00065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 02/05/2018] [Accepted: 03/22/2018] [Indexed: 12/14/2022] Open
Abstract
Adoption of the model for end-stage liver disease score by Organ Procurement and Transplant Network (OPTN) deceased donor liver allocation policy in 2002 has led to an increase in the number of simultaneous liver kidney (SLK) transplantation. Since kidney function recovery following liver transplantation is difficult to predict, allocation of the kidney for SLK transplantation thus far has not been based on much rationale and evidence. Lack of OPTN policy towards SLK organ allocation has resulted in great variations among transplant centers regarding SLK transplantation. Increasing use of kidneys towards SLK transplantation diverts deceased donor kidneys away from candidates awaiting kidney-alone transplantation. Recently OPTN/United Network of Organ Sharing has implemented medical eligibility criteria for adult SLK transplantation which also includes a concept of safety net. Implementation of the new policy is a move in a positive direction, providing consistency in our practice and evidence-based guidelines in selecting candidates for SLK transplantation. This policy needs to be monitored prospectively and modified based on new data that will emerge over time. This review outlines the literature on SLK transplantation and efforts towards developing rational policy on SLK organ allocation.
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Affiliation(s)
- Sabiha M. Hussain
- Division of Nephrology and Hypertension, Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
| | - Kalathil K. Sureshkumar
- Division of Nephrology and Hypertension, Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
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Yunhua T, Qiang Z, Lipeng J, Shanzhou H, Zebin Z, Fei J, Zhiheng Z, Linhe W, Weiqiang J, Dongping W, Zhiyong G, Xiaoshun H. Liver Transplant Recipients With End-Stage Renal Disease Largely Benefit From Kidney Transplantation. Transplant Proc 2018; 50:202-210. [PMID: 29407310 DOI: 10.1016/j.transproceed.2017.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/11/2017] [Accepted: 11/03/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND The incidence of end-stage renal disease (ESRD) after liver transplant (LT) has increased. The actual benefit of kidney transplantation (KT) is not completely understood in LT recipients with ESRD. METHODS We analyzed Scientific Registry of Transplant Recipients data for all KT candidates with prior LT from 1998 to 2014; the benefits of KT relative to remaining on dialysis were compared by means of multivariate Cox proportional hazards regression analysis. RESULTS The number of these KT candidates with prior LT has tripled from 98 in 1998 to 323 in 2015; LT recipients with ESRD remaining on dialysis have a 2.5-times increase in the risk of liver graft failure and a 3.6-times increase in the risk of patient death compared with these patients receiving KT. The adjusted liver graft and patient survival rates after donors from donation after cardiac death or expanded-criteria donor kidney transplantation were significantly higher than in patients remaining on dialysis in LT recipients with ESRD. CONCLUSIONS The number of referrals to KT with prior LT is increasing at a rapid rate. Remaining on dialysis in LT recipients with ESRD has profound increased risks of liver graft failure and patient death in comparison to receiving a KT. LT recipients with ESRD can benefit from expanded-criteria donor and donation after cardiac death kidney transplantation.
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Affiliation(s)
- T Yunhua
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Z Qiang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - J Lipeng
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - H Shanzhou
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Z Zebin
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - J Fei
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Z Zhiheng
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - W Linhe
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - J Weiqiang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - W Dongping
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - G Zhiyong
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China.
| | - H Xiaoshun
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China.
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Aeder MI. Simultaneous Liver-Kidney Transplantation: Policy Update and the Challenges Ahead. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0190-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Grant L, Tujios S, Singal AG. Outcomes of simultaneous liver-kidney transplantation: implications for patient selection. Curr Opin Organ Transplant 2018; 23:264-270. [PMID: 29356707 DOI: 10.1097/mot.0000000000000501] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Rates of simultaneous liver kidney (SLK) transplantation have continued to increase despite lack of clear allocation guidelines and outcomes data. The organ procurement and transplantation network (OPTN)/UNOS board approved a new SLK allocation policy to standardize medical eligibility and optimize organ utilization. This review highlights the rationale behind these new selection criteria and posttransplant outcomes in various patient populations. RECENT FINDINGS Uniform criteria for SLK transplantation were adopted in August 2017 and state SLK should be reserved for select patients with cirrhosis who have chronic kidney disease for longer than 3 months, sustained acute kidney injury, or particular metabolic diseases. Many patients who previously underwent SLK did not meet these criteria, reducing organ availability for patients awaiting kidney-alone transplantation. The new criteria includes a 'safety net' policy allowing for renal transplant priority for liver-alone recipients who do not meet criteria for SLK but fail to have renal recovery within the first year. SUMMARY The new SLK allocation policy was adopted to avoid kidney transplantation in those patients who have a significant chance of recovering renal function post-liver transplant and those with a poor chance of survival in whom SLK is futile.
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Modi RM, Tumin D, Kruger AJ, Beal EW, Hayes Jr D, Hanje J, Michaels AJ, Washburn K, Conteh LF, Black SM, Mumtaz K. Effect of transplant center volume on post-transplant survival in patients listed for simultaneous liver and kidney transplantation. World J Hepatol 2018; 10:134-141. [PMID: 29399287 PMCID: PMC5787677 DOI: 10.4254/wjh.v10.i1.134] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 12/01/2017] [Accepted: 12/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To examine the effect of center size on survival differences between simultaneous liver kidney transplantation (SLKT) and liver transplantation alone (LTA) in SLKT-listed patients.
METHODS The United Network of Organ Sharing database was queried for patients ≥ 18 years of age listed for SLKT between February 2002 and December 2015. Post-transplant survival was evaluated using stratified Cox regression with interaction between transplant type (LTA vs SLKT) and center volume.
RESULTS During the study period, 393 of 4580 patients (9%) listed for SLKT underwent a LTA. Overall mortality was higher among LTA recipients (180/393, 46%) than SLKT recipients (1107/4187, 26%). The Cox model predicted a significant survival disadvantage for patients receiving LTA vs SLKT [hazard ratio, hazard ratio (HR) = 2.85; 95%CI: 2.21, 3.66; P < 0.001] in centers performing 30 SLKT over the study period. This disadvantage was modestly attenuated as center SLKT volume increased, with a 3% reduction (HR = 0.97; 95%CI: 0.95, 0.99; P = 0.010) for every 10 SLKs performed.
CONCLUSION In conclusion, LTA is associated with increased mortality among patients listed for SLKT. This difference is modestly attenuated at more experienced centers and may explain inconsistencies between smaller-center and larger registry-wide studies comparing SLKT and LTA outcomes.
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Affiliation(s)
- Rohan M Modi
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, United States
| | - Andrew J Kruger
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Eliza W Beal
- Department of General Surgery, Division of Transplantation, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Don Hayes Jr
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Section of Pulmonary Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, United States
| | - James Hanje
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Anthony J Michaels
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Kenneth Washburn
- Department of General Surgery, Division of Transplantation, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Lanla F Conteh
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Sylvester M Black
- Department of General Surgery, Division of Transplantation, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Khalid Mumtaz
- Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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MELD Stratified Outcomes Among Recipients With Diabetes or Hypertension: Simultaneous Liver Kidney Versus Liver Alone. J Clin Gastroenterol 2018; 52:67-72. [PMID: 28906426 DOI: 10.1097/mcg.0000000000000818] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIM Data are scanty on allocating simultaneous liver kidney (SLK) based on model for end-stage disease (MELD) score. Diabetes mellitus (DM) and hypertension (HTN) are frequent in cirrhosis patients. We analyzed transplant recipients with DM and/or HTN to compare MELD-based outcomes of SLK to liver transplantation alone (LTA). MATERIALS AND METHODS Of 13,584 first deceased donor liver transplantation among patients with DM and/or HTN (1530 or 11.2% SLK), MELD score predicted SLK [1.02 (1.01-1.03)]. SLK was beneficial for 5-year patient survival at MELD score ≥43 (78.6% vs. 62.6%, P=0.017), but not at MELD score <29 (74.8% vs. 76.2%, P=0.63). Among 11,405 recipients (976 SLK) at MELD score <29, SLK (n=816) was beneficial compared with 706 LTA [75% vs. 64%, P<0.001; 0.71 (0.55-0.91)] at serum creatinine (SC) ≥2 but not at SC<2 [73% vs. 76%, P=0.32; 0.85 (0.60-1.2)]. Among patients with MELD score 29 to 42, SLK (n=484) and LTA (n=1403) had similar survival [69% vs. 69%, P=0.58; 0.9 (0.7-1.5)]. Among patients with MELD score ≥43, SLK (n=70) was associated with 35% improved patient survival at 5 years compared with 222 LTA [0.65 (0.46-0.93)]. CONCLUSIONS Among patients with DM and/or HTN, SLK is useful at: (a) MELD score <29 and SC≥2 and (b) MELD score ≥43. Prospective studies are needed to confirm these findings as basis to optimize use of SLK.
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Yadav K, Serrano OK, Peterson KJ, Pruett TL, Kandaswamy R, Bangdiwala A, Ibrahim H, Israni A, Lake J, Chinnakotla S. The liver recipient with acute renal dysfunction: A single institution evaluation of the simultaneous liver-kidney transplant candidate. Clin Transplant 2017; 32. [DOI: 10.1111/ctr.13148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2017] [Indexed: 01/15/2023]
Affiliation(s)
- Kunal Yadav
- Division of Transplantation; Department of Surgery; Virginia Commonwealth University; Richmond VA USA
| | - Oscar K. Serrano
- Division of Transplantation; Department of Surgery; University of Minnesota; Minneapolis MN USA
| | - Kent J. Peterson
- Division of Transplantation; Department of Surgery; University of Minnesota; Minneapolis MN USA
| | - Timothy L. Pruett
- Division of Transplantation; Department of Surgery; University of Minnesota; Minneapolis MN USA
| | - Raja Kandaswamy
- Division of Transplantation; Department of Surgery; University of Minnesota; Minneapolis MN USA
| | - Ananta Bangdiwala
- Division of Biostatistics; School of Public Health; University of Minnesota; Minneapolis MN USA
| | - Hassan Ibrahim
- Department of Medicine; University of Minnesota; Minneapolis MN USA
| | - Ajay Israni
- Department of Medicine; University of Minnesota; Minneapolis MN USA
| | - John Lake
- Department of Medicine; University of Minnesota; Minneapolis MN USA
| | - Srinath Chinnakotla
- Division of Transplantation; Department of Surgery; University of Minnesota; Minneapolis MN USA
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