Combined liver and kidney transplant (CLKT) involves transplanting both organs simultaneously. The first successful CLKT was reported in 1984. Between 1988-2007, over 2800 CLKT procedures were performed in the US. CLKT offers advantages over transplanting either organ alone such as fewer surgeries, lower immunosuppression needs, and better survival rates. Strict criteria must be met for CLKT and donor organs with good renal function are preferred. Outcomes for CLKT are superior to liver transplant alone or kidney transplant after liver transplant. CLKT is recommended for conditions affecting both the liver and kidneys such as primary hyperoxaluria.
2. Introduction
• The first successful combined liver-kidney transplantation (CLKT) in an adult was
reported in 1984- Margreiter et al
• Recipient, a 32-year-old man with hepatitis B cirrhosis, had previously undergone
a kidney transplantation 6 years earlier, making this first case both a subsequent
and simultaneous transplant.
• Between 1988 and 2007, there were 2829 CLKT procedures performed in
the United States of which only 166 were carried out in children
3. Advantage of CLKT
• Single surgery
• Lower immunosuppression dose
• Better survival than when one organ alone is transplanted
• Recipients who subsequently require kidney transplant may have a harder
time finding a suitable graft because of sensitization from both the liver
graft and blood product administration at the initial transplant event.
5. New policy
• Higher MELD scores accrued by patients with renal failure, a higher
proportion of CLKT candidates (over liver transplant alone) are likely
to be transplanted.
• proportion of CLKT recipients end up with three functioning kidneys.
• valuable graft years that might have otherwise benefited kidney
transplant alone (KTA) recipients for a considerably longer duration
are lost with CLKT
6. SAFETY NET
• patients with chronic kidney disease (CKD) who require liver
transplantation (LT) should receive consideration for both liver and
kidney. Dialysis after transplant has been shown to predict both poor
survival for patients and liver grafts. Recent studies continue to
support this practice, with a UNOS review showing an approximately
35% increased risk for graft loss in liver-only recipients with CKD
who require dialysis after LT
7. New policy
• new policy was developed to govern dual liver-kidney allocation
Adopted nationwide by United Network for Organ Sharing/Organ
Procurement and Transplantation Network (UNOS/OPTN)
• current policy dictates that stringent medical criteria are met and
provides a safety net for patients with renal nonrecovery after LT
alone
8.
9.
10. Indications
• Decompensated chronic liver disease with CKD or HRS on hemodialysis (longer than 8
weeks)
• Primary hyperoxaluria
• Atypical hemolytic uremic syndrome
• Nephronophthisis is associated with liver fibrosis
• Alpha 1-antitrypsin deficiency
• Hereditary C3 deficiency
• Lecithin cholesterol acyltransferase deficiency and
• Glycogen storage diseases
11.
12. CONTRAINDICATIONS FOR CLKT
• Active infection
• Recent or active malignancy
• Severe irreversible heart or respiratory failure
• Severe non-adherence, and psychiatric disorder impairing consent or
adherence
• Moderate or severe Porto- pulmonary hypertension
13. Predictors for renal graft failure
• Hyperlipidemia
• Longer duration of renal replacement
• longer kidney cold time
• and poorer kidney graft quality
• Higher MELD score at transplant and
• Longer pretransplant hospitalization
14. DONOR SELECTION
• Patients with renal failure after SLK had profoundly inferior 1- and 3-
year survival rates compared with those with functioning kidney graft
(18.2% and 13.5% versus 92.6% and 83.7%; P < 0.01)
• Predictors for renal graft failure included measured by the Kidney
Donor Risk Index. .
15.
16. DONOR SELECTION
• donors selected for a CLKT should be younger
• Donors should have good renal function as assessed by serum
creatinine level, urine output, and urinalysis
• A high-risk medical comorbidities (hypertension, diabetes,
nephrolithiasis) or divergent laboratory data should be approached
with caution and a kidney biopsy obtained at the time of retrieval
17. DONOR SELECTION
• Acceptable biopsy results include the absence of significant
arteriolosclerosis, glomerulopathy
• acute tubular necrosis; (these donors will usually recover function.)
• dense acute tubular necrosis with microscopic findings of
intraglomerular fibrin thrombi, suggestive of severe disseminated
intravascular coagulopathy in the donor, may pose a greater risk for
renal allograft recovery.
18. Immunosuppression
• Immunoprotective effects of CLKT on renal allograft
• reductions in both acute cellular rejection and chronic rejection of kidney
allograft in those who undergo CLKT when compared to cadaveric renal
transplantation
• Renal-sparing regimen is employed. Calcineurin inhibitor introduction is delayed .
Steroids are weaned gradually with a low-maintenance daily dose (5 mg)
19. CLKT vs KALT and SPKT
• Survival for KALT recipients was 10% worse than for patients with
SLK
• This was particularly pronounced with early (<3 months) and
late (>12 months) KALT, suggesting that the contribution of
kidney failure was underappreciated at the time of LT listing.
KPT
20. CLKT vs KALT and SPKT
• Patients with simultaneous liver-kidney transplantation (SLK)
have superior liver graft and patient survival compared with
both liver-only recipients who require post-LT dialysis and kidney
after liver transplant (KALT) recipients
• Kidney grafts for SLK have at least equivalent and per-haps
superior long-term survival when compared with counterparts
transplanted as kidney only or simultaneous pancreas-kidney
transplantation (SPKT)
21. CLKT vs KALT and SPKT
• No difference in survival was observed between the SLK and
KALT groups when the latter received a kidney 6 to 12 months after
the liver.
• These results are most instructive, because this is the group
most likely to be eligible for the newly proposed safety net.
• Outcomes for liver graft survival similarly showed a clear
benefit for SLK over KALT
24. CLKT vs KALT and SPKT
• UNOS data Comparing outcomes of high-quality mate kidneys
that went to SLK versus KTA or SPKT, Cannon et al. that by 6.5
years from transplant, the kidney grafts in SLK had equivalent survival
to the other groups
• By 10 years, the cumulative incidence rate of graft failure was
actually higher in the KTA and SPKT groups compared with SLK
(21% versus 11%; P < 0.01)
25. Primary hyperoxaluria
• Primary hyperoxaluria type 1 (PH-1) is a rare disorder of oxalate
metabolism which has an incidence of 1:120000
• elevated plasma and urinary oxalate levels due to the defective
liver-specific peroxisomal enzyme alanine/glyoxylate
aminotransferase
• deposition of insoluble calcium salts in the kidney
• PH-1 develop early-onset nephrocalcinosis, nephrolithiasis and
ESRD.
27. • PH-1 often has a variable age of onset for ESRD
• oxaluria is responsive to pyridoxine in some children.
• Therefore, it is important that pyridoxine responsiveness is
evaluated and DNA analysis is performed to confirm the diagnosis
in all children before planning CLKT
28.
29.
30. Conclusion
• Model for End-Stage Liver Disease (MELD) era has seen a drastic
increase in the number of CLKTs performed annually. Judicious use of
kidney allografts is warranted.
• proper evaluation of donor kidney function should not be overlooked;
delay in return of renal function can alter the postoperative course of
the CLKT recipient.
• Early kidney after liver transplantation is a viable alternative to CLKT
for patients with persistent renal failure after transplant, only if
rapidly available
31. Conclusion
• Salvage CLKT after liver transplantation portends a poor Prognosis
and is not recommended.
• For patients with hepatorenal syndrome or acute kidney injury, the
current recommendation for CLKT is a minimum 6 weeks of
hemodialysis before transplant.
• The use of intraoperative continuous Veno venous hemodialysis
during combined liver and kidney transplantation (CLKT) is beneficial
in managing fluid and electrolyte balance.
