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INDICAZIONI AL TRAPIANTO COMBINATO DI FEGATO-

RENESezione di Nefrologia

Sezione di Nefrologia

U.O. Chirurgia generale e dei Trapianti Prof. A.D. PinnaAzienda Ospedaliera Policlinico S.Orsola-Malpighi

Università degli Studi di Bologna

Liver-Kidney TransplantationBackground

Nadim M.K.et al., Am. J. Transpl. 2012


Fong T.L. et al., Transplantation. 2012


Martin E.L.,et al., Liver Transpl. 2012


Eason J.,et al., Am. J. Transpl. 2008


• Mainly the indication to combined liver-kidney transplantation is a liver disease that caused also a chronic kidney insufficiency (Serum creatinine > 2 mg/dL)

• The most frequent indications are: liver cirrhosis virus or alchol related, policystic disease, genetics or metabolics disorders, cholestatic disease.

• As a result, liver-kidney transplantation is considered a safe procedure and the immunosuppressive regimen that should be adopted is debated

• Recipient selection is critical especially within MELD-based systems

Liver-kidney transplantationAim

To report a series of liver-kidney transplantation

for adult recipients performed at a single center

and to evaluate the different results considering

indications and the impact of different

immunosuppressive strategy

Liver-kidney transplantationAim

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 grafts

5 Right extended – 2 Left lateral segments

• Only AB0-compatible donors were used

• Among 57 listed patients for combined liver-kidney transplant:

4747 (82%) were effectively transplanted (82%) were effectively transplanted 5 (9.1%) dead on waiting list5 (9.1%) dead on waiting list 3 (5.5%) were in stand-by 3 (5.5%) were in stand-by 1 (1.8%) was on the waitng list1 (1.8%) was on the waitng list 1 (1.8%) refused the combined liver-kidney transplant1 (1.8%) refused the combined liver-kidney transplant

Study population

Liver Kidney transplantations

Study population

MELD

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)

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

Liver-Kidney TransplantationResults: Outcome

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

Liver Kidney transplantationResults: Complications

Infections 17 (37.8%)

Acute cellular liver rejectionsKidney rejection

3 / 47 (6%)4 / 47 (8%)

De novo cancer:

- Kidney cancer- Larynx cancer- Skin cancer

3 /47 (6%)

111

Liver-Kidney TransplantationResults: donor features

Age (years) 41.9 ± 17.3 (13 – 81)

Cause of death

Trauma 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)

Liver-Kidney TransplantationResults: Indications

Indication for Liver-Kidney transplantation:

Liver disease

Policistyc disease 17 (36%)

CirrhosisHCVHBVAlchol

11(22%) 5 (11%) 4 (9%)

Genetic/metabolic 6 (13%)

Cholestatic 2 (4%)

HCC on cirrhosis 2 (4%)

Liver-Kidney TransplantationResults: Indications

Indication 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%)

Liver Kidney TransplantationsResults: post-op. complications

Vascular complic. 3 (6%)

Biliary compl. 7 (15%)

Neurological compl. 3 (6%)

Surgical reoperations 7 (15%)2 Liver re-TX: - HA thrombosis

- Small for size syndrome

2 Kidneys transplantectomy: - 2 R. V. thrombosis

1 Splenectomy for platelets disorders2 Nephrectomy of native kidney

Post-operative Dialysis 7 (15%)

Liver-Kidney TransplantationResults: outcome

100%

66.7%

80%

60%

Del Gaudio M. et al, Transpl. Proc. 2013 IN PRESS


69.2%

85.7%



P=0.04

TacrolimusThrough level

ng/mL



65.6%

75%


Conclusions

• Liver-kidney transplantation is a safe and effective procedure.

• Even in the MELD era with cadaveric marginal donors, the

transplantation rate of listed patients is high with acceptable dropout from

the waiting list

• The standard immunosuppressive regimen based on Tacrolimus and

steroids can be ameliorated by induction therapy with Alemtuzumab

(Campath).

• An adjusted MELD score for this kind of recipients can be shortening the

time on waiting list

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