Simultaneous Liver Kidney Transplantation: Stealing or Saving?
That was the topic of a hotly debated 3 lecture session presented by Dr. Nadim from the University of Southern California, Dr. Charlton from Mayo Clinic, and Dr. Levitsky from Chicago. Audience members included nephrologists, hepatologists, and surgeons among others. Here are a few key points that I took away from the session:
1. There is no simple reliable way to measure GFR in cirrhotic patients. This makes it very difficult to assess such patients for CKD.
2. There is no standard definition to assess AKI in cirrhotic patients, although using the AKIN criteria may help ameliorate this problem. Because of inconsistent definitions in the literature, the incidence of AKI in cirrhotics have ranged from 5% to 70%.
3. The traditional definition and classification of hepatorenal syndrome is inadequate. Using creatinine in the definition may not be optimal. It is also often difficult to distinguish HRS from ATN in a hospitalized setting even with urine electrolytes. And why can’t someone with CKD have superimposed HRS?
4. Liver transplant recipients have poor 1 year survival if they require renal replacement therapy post transplantation. This is the impetus for performing simultaneous liver kidney transplants.
5. It is very difficult to predict which patients will develop ESRD after a liver transplant because it is hard to determine who has CKD. Kidney biopsy may be helpful, as studies suggest that patients with >30% fibrosis are likely to go on to ESRD post liver transplantation. Problem is that performing the biopsy in a cirrhotic patient is easier said than done.
6. Simultaneous liver kidney transplant recipients may have a better 1 year survival than those with liver transplant alone. This was hotly debated especially by the nephrologists in the audience. The problem is that the studies are heavily biased by selection and there are no prospective randomized studies to support this (there probably won’t be either).
7. The one clear benefit for simultaneous liver kidney transplants is in patients who have been on dialysis for over 6 weeks.
8. Native kidney function usually contributes a small amount in patients who appropriately receive simultaneous liver kidney transplants.
9. Kidney transplants may not be protected immunologically by the patient also receiving a liver transplant. Data was presented suggesting that kidney outcome in simultaneous liver kidney recipients is inferior to kidney transplant alone patients. This may be related to inadequate immunosuppression and inadequate pretransplant immunologic testing.
So is the simultaneous liver kidney transplant stealing or saving? In patients with true ESRD, there is definitely a benefit. In all the other cases, it seems to depend who you ask.
Post written by Dr. Vinay Nair, eAJKD Advisory Board member.
Check out all of eAJKD’s coverage of the 2013 American Transplant Congress.