Il trapianto combinato di fegato e rene - Gastrolearning®

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Gastrolearning XVIII lezione
Il trapianto combinato di fegato e rene - Prof. D. Pinna (Università di Bologna).

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Il trapianto combinato di fegato e rene - Gastrolearning®

  1. 1. INDICAZIONI AL TRAPIANTOCOMBINATO DI FEGATO-RENESezione di NefrologiaSezione di NefrologiaU.O. Chirurgia generale e dei Trapianti Prof. A.D. PinnaAzienda Ospedaliera Policlinico S.Orsola-MalpighiUniversità degli Studi di Bologna
  2. 2. Liver-Kidney TransplantationBackgroundNadim M.K.et al., Am. J. Transpl. 2012
  3. 3. Liver-Kidney TransplantationBackgroundNadim M.K.et al., Am. J. Transpl. 2012
  4. 4. Liver-Kidney TransplantationBackgroundNadim M.K.et al., Am. J. Transpl. 2012
  5. 5. Liver-Kidney TransplantationBackgroundNadim M.K.et al., Am. J. Transpl. 2012
  6. 6. Liver-Kidney TransplantationBackgroundNadim M.K.et al., Am. J. Transpl. 2012
  7. 7. Liver-Kidney TransplantationBackgroundFong T.L. et al., Transplantation. 2012
  8. 8. Liver-Kidney TransplantationBackgroundMartin E.L.,et al., Liver Transpl. 2012
  9. 9. Liver-Kidney TransplantationBackgroundEason J.,et al., Am. J. Transpl. 2008
  10. 10. Liver-Kidney TransplantationBackground• Mainly the indication to combined liver-kidney transplantationis a liver disease that caused also a chronic kidney insufficiency(Serum creatinine > 2 mg/dL)• The most frequent indications are: liver cirrhosis virus or alcholrelated, policystic disease, genetics or metabolics disorders,cholestatic disease.• As a result, liver-kidney transplantation is considered a safeprocedure and the immunosuppressive regimen that should beadopted is debated• Recipient selection is critical especially within MELD-basedsystems
  11. 11. Liver-kidney transplantationAimTo report a series of liver-kidney transplantationfor adult recipients performed at a single centerand to evaluate the different results consideringindications and the impact of differentimmunosuppressive strategy
  12. 12. Liver-kidney transplantationAim
  13. 13. Liver-KidneyTransplantationMethods: study period• Retrospective study with prospectively collected data• Period: January 1997 – December 2012• 47 Liver-Kidney transplantations in adult patients• 40 (84.4%) whole liver• 7 (15.6%) split liver grafts5 Right extended – 2 Left lateral segments• Only AB0-compatible donors were used
  14. 14. • Among 57 listed patients for combined liver-kidneytransplant:4747 (82%) were effectively transplanted(82%) were effectively transplanted5 (9.1%) dead on waiting list5 (9.1%) dead on waiting list3 (5.5%) were in stand-by3 (5.5%) were in stand-by1 (1.8%) was on the waitng list1 (1.8%) was on the waitng list1 (1.8%) refused the combined liver-kidney transplant1 (1.8%) refused the combined liver-kidney transplantStudy population
  15. 15. Liver Kidney transplantationsStudy populationMELD
  16. 16. Liver-Kidney TransplantationResults: Recipient characteristics• Mean age of recipient 49.91 ± 9.87 (14-65)• Sex of recipient (M/F) 27 (57%) / 20 (43%)• Mean MELD at time of LKT 22.16 ± 7.39 (11-42)• Mean Time on waiting list (months) 8.11 ± 9.75 (0.1- 35.76)• Follow-up (years) 3.74 ± 3.01 (0.01- 9.87)
  17. 17. Liver-Kidney TransplantationResults: Recipient characteristics• Serum creatinine at listing mg/dL 4.87 ± 2.89• GFR at listing 25.38 ± 19.58• Serum creatinine at time of LKTx 4.48 ±2.49• GFR at time of LKTx 24.72 ± 18.5• Dialysis at time of LKTx 23/47
  18. 18. Liver-Kidney TransplantationResults: Outcome
  19. 19. Liver-Kidney TransplantationResults: Immunosuppressive regimen• Ciclosporine (Neoral) 5/47+• Tacrolimus (Prograf) 42/47• Induction with Alemtuzumab (Campath)(0.3 mg/kg) on day 0 and day 7 13/42• Change of immunosuppresive therapy:- Sirolimus (Rapamune) 5/47 (11%)- MMF (Cellcept) 9/47 (20%)- No change 33/47 (69%)Steroids
  20. 20. Liver Kidney transplantationResults: ComplicationsInfections 17 (37.8%)Acute cellular liver rejectionsKidney rejection3 / 47 (6%)4 / 47 (8%)De novo cancer:- Kidney cancer- Larynx cancer- Skin cancer3 /47 (6%)111
  21. 21. Liver-Kidney TransplantationResults: donor featuresAge (years) 41.9 ± 17.3 (13 – 81)Cause of deathTrauma 16 (36%)Cerebrovascular 21 (47%)Other 8 (17%)HBcore positive 8 (17%)HCV positive 1 (2%)Liver mean ischemia time (min.)Kidney mean ischemia time (min.)376 ± 83.99 (235-644)761.35 ± 168.24 (480-1380)
  22. 22. Liver-Kidney TransplantationResults: IndicationsIndication for Liver-Kidney transplantation:Liver diseasePolicistyc disease 17 (36%)CirrhosisHCVHBVAlchol11(22%)5 (11%)4 (9%)Genetic/metabolic 6 (13%)Cholestatic 2 (4%)HCC on cirrhosis 2 (4%)
  23. 23. Liver-Kidney TransplantationResults: IndicationsIndication for Liver-Kidney transplantation:Kidney diseasePolicistyc disease 16 (36%)End Stage Kidney disease 8 (18%)GN IgA 3 (6.6%)GNC 3 (6.6%)GSFS 2 (4%)Interstitial nephrites 2 (4%)Vascular disease (hypertension+diabetes) 2 (4%)Amyloidotic nephropathy 1 (2.2%)Cryoglobulinemic syndrome 1 (2.2%)Hyperoxaluria type 1 1 (2.2%)Glicogenosis 1 (2.2%)Unknown disease 5 (11%)
  24. 24. Liver Kidney TransplantationsResults: post-op. complicationsVascular complic. 3 (6%)Biliary compl. 7 (15%)Neurological compl. 3 (6%)Surgical reoperations 7 (15%)2 Liver re-TX: - HA thrombosis- Small for size syndrome2 Kidneys transplantectomy: - 2 R. V. thrombosis1 Splenectomy for platelets disorders2 Nephrectomy of native kidneyPost-operative Dialysis 7 (15%)
  25. 25. Liver-Kidney TransplantationResults: outcome100%66.7%80%60%Del Gaudio M. et al, Transpl. Proc. 2013 IN PRESS
  26. 26. Liver-Kidney TransplantationResults: outcome69.2%85.7%Del Gaudio M. et al, Transpl. Proc. 2013 IN PRESS
  27. 27. Liver-Kidney TransplantationResults: outcomeP=0.04TacrolimusThrough levelng/mLDel Gaudio M. et al, Transpl. Proc. 2013 IN PRESS
  28. 28. Liver-Kidney TransplantationResults: outcome65.6%75%Del Gaudio M. et al, Transpl. Proc. 2013 IN PRESS
  29. 29. Conclusions• Liver-kidney transplantation is a safe and effective procedure.• Even in the MELD era with cadaveric marginal donors, thetransplantation rate of listed patients is high with acceptable dropout fromthe waiting list• The standard immunosuppressive regimen based on Tacrolimus andsteroids can be ameliorated by induction therapy with Alemtuzumab(Campath).• An adjusted MELD score for this kind of recipients can be shortening thetime on waiting list

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