H- 11: Criteria for multiple organ transplantation
A- ARF quoted without specification
Renal Function and Transplantation in Liver Disease
Parajuli, Sandesh MBBS1; Foley, David MD2; Djamali, Arjang MD1,2; Mandelbrot, Didier MD1
Author Information
1
Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine
and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI.
2
Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of
Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI.
Correspondence: Didier Mandelbrot, MD, Division of Nephrology, Department of Medicine, 4177
MFCB, 1685 Highland Avenue, Madison, WI 53705.
Journal : Transplantation
Year : 2015 / Month : September
Volume : 99
Pages: 1756–1764
DOI: 10.1097/TP.0000000000000820
ABSTRACT
Kidney injury is associated with increased morbidity and mortality in liver transplant recipients. Since
the introduction of the model for end-stage liver disease for the allocation of organs for liver
transplantation in 2002, the heavy weighting of serum creatinine in the model for end-stage liver
disease score has significantly increased the incidence of renal dysfunction seen among patients
undergoing liver transplantation. As a result, the frequency of simultaneous liver-kidney (SLK)
transplantation compared to liver transplantation alone (LTA) has also increased. The decision to
perform SLK rather than LTA is an important one because the benefits to the liver transplant recipient
receiving a kidney transplant must be balanced with the benefits of using that organ for a patient with
end-stage renal disease. However, predicting whether or not a patient with liver failure has reversible
kidney disease, and therefore does not also need a kidney transplant, is difficult. The severity and
duration of pretransplant renal dysfunction, hepatitis c, diabetes, and other risk factors for kidney
disease are associated with an increased risk of posttransplant end-stage renal disease. However,
there are currently no clinical findings that accurately predict renal recovery post liver transplant. As a
result, the rate of SLK versus LTA differs significantly between transplant centers. To increase
consistency across centers, multiple guidelines have been proposed to guide the decision between
SLK and LTA, but their poor predictive value has limited their uniform adoption. Nevertheless, adoption
of uniform rules for the allocation of kidneys would reduce the variability between centers in rates of
SLK transplant.
COMMENTS
Renal dysfunction, both before and after liver transplantation, is a major complicating factor associated
with increased morbidity, mortality, and cost. The prevalence of CKD in liver transplant recipients
ranges from 20% to 80%.
The risk of developing end-stage renal disease (ESRD) requiring renal replacement therapy (RRT)
ranges from 2% to 5% per year after liver transplant alone (LTA).
The decision to perform SLK rather than LTA is important, because the benefits to the patient with liver
disease of receiving a kidney transplant must be balanced with the downside of not being able to use
that organ for a patient with ESRD. The critical question to answer is which patients with pretransplant
renal dysfunction or failure have reversible versus irreversible renal dysfunction, because those with
reversible dysfunction should receive a LTA, whereas irreversible, severe dysfunction is the indication
for SLK.
In this review, the authors gather existing data on predicting whether or not a patient with liver failure
has reversible kidney disease, as well as arguments for and against erring on the side of performing
SLK versus LTA transplants.
Acute kidney injury in advanced liver disease is common but likely underestimated because of falsely
low serum creatinine levels. The incidence of AKI in liver disease is poorly defined.
After liver transplantation, AKI is also common. Many intraoperative factors may contribute to the
development of AKI including intraoperative hemodynamic instability requiring high-dose vasopressors,
severe postreperfusion syndrome, or the need for either aortic or inferior vena cava cross-clamping.
Ten years after liver transplantation, approximately 18% of patients will develop ESRD, and many of
them will be considered for kidney transplantation. The rate of development and progression of
posttransplantation CKD can potentially be reduced with careful preoperative and perioperative care.
Well balanced guidelines concerning the dual liver and kidney transplantation are presently missing.
Pr. Jacques CHANARD
Professor of Nephrology