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Combined liver and kidney transplantation has been steadily applied in major transplantation centers, saving the lives of many patients with end-stage liver and renal failure. However, there are still multiple unresolved problems in the clinical diagnosis, treatment and long-term prognosis of combined liver and kidney transplantation. By referring to "Technical Operating Standards for Combined Liver and Kidney Transplantation (2019 Edition)" and the latest published literature and guidelines at home and abroad, "Guidelines for Clinical Diagnosis and Treatment of Combined Liver and Kidney Transplantation" was formulated. Recommendations and suggestions were delivered regarding the surgical indications and contraindications, preoperative preparation and evaluation, the timing of transplantation for end-stage liver and kidney diseases, the selection of surgical approaches and postoperative follow-up, specific pathophysiology, surgical techniques, complication management and immunosuppressive treatment of combined live and kidney transplantation, aiming to enhance the utilization rate of grafts and improve the survival and prognosis of combined liver and kidney transplant recipients.
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Primary hyperoxaluria type Ⅱ (PH2) is an inherited disorder of the glyoxylate metabolism caused by the gene mutation of glyoxylate reductase/hydroxypyruvate reductase (GRHPR). PH2 is characterized by recurrent nephrolithiasis and nephrocalcinosis, which may even progress into end-stage renal disease. Currently, organ transplantation is the only treatment option for PH2, which mainly includes two strategies: kidney transplantation and combined liver and kidney transplantation. Kidney transplantation yields a high risk of recurrence of oxalate nephropathy, which may cause early graft dysfunction. Combined liver and kidney transplantation could mitigate the deficiency of oxalate metabolism, whereas it yields a high risk of graft complications. PH2 is an extremely rare disorder. No consensus has been reached on the indications, surgical selection and perioperative management of organ transplantation for PH2 patients. In this article, the pathogenesis, diagnosis, monitoring and organ transplantation experience of PH2 were reviewed, aiming to divert clinicians' attention to PH2 and provide reference for determining diagnosis and treatment regimens, especially transplantation strategy for PH2 patients.
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Objective To investigate the metabolic differences of Tacrolimus in different transplant recipients. Methods A retrospective study was conducted, 30 patients of the organ transplant admitted to organ transplantation center of General Hospital of Chinese People's Armed Police Forces from January 2002 to August 2012 were enrolled, and they were divided into combined liver and kidney transplant (SLK) group, single liver transplant group and single renal transplant group, 10 cases in each group. The SLK group and the simple liver transplantation group were given the same drug regimen, methylprednisolone injection was given during operation, and tacrolimus+ mycophenolate mofetil+ prednisone triple immunosuppressive therapy was taken after operation, on the first day after operation, the initial dose of tacrolimus was given 0.06 mg·kg-1·d-1 divided into 2 times taken orally, and on the third day after operation, the concentration of tacrolimus was detected; after operation group for 2 - 4 days, single renal transplantation group was given tacrolimus the initial dose of tacrolimus 0.15 mg·kg-1·d-1 was divided into 2 parts for twice oral administration, after 2 - 3 days of the above treatment, monitoring the concentration of tacrolimus began. One month after transplantation, the metabolic differences of tacrolimus among the three groups were compared.Results One month after operation, the oral tacrolimus doses (μg·kg-1·d-1: 74.78±32.65 vs. 80.62±24.02, 85.58±16.78) and the monitored blood drug concentration (μg/L: 6.64±2.73 vs. 7.50±3.08, 7.46±3.20) in SLK group were lower than either the single liver transplantation group or single renal transplantation group, but the comparisons among the three groups, there were no statistically significant differences(allP > 0.05).Conclusions In SLK group, the protective effect of transplanted liver on transplanted kidney may be related to the length of postoperative time. Liver transplantation performed within post-operative one month has no protective effect on the transplanted kidney.
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Objective To summarize the experience of treating the end stage of liver disease complicated with renal failure using combined liver-kidney transplantation.Methods The clinical data of 28 cases receiving combined liver-kidney transplantation were retrospectively analyzed, including the inclusion criteria of surgical indications, modus operandi, protocol of immunosuppression and the prognosis post-operation.Results Among these 28 cases in our study, 22 cases suffered from liver and renal failure, accounting for 78.6%; 4 cases were diagnosed as having hepatorenal syndrome, accounting for 14.3%; and 1 case had hyperoxaluria and polycystic liver with polycystic kidney. As for the modus operandi we used, piggy-back procedure was adopted for 4 patients and classic procedure without bypass was used for the rest. Donor kidneys were all put in the right iliac fossa. During the follow-up period of 5 months to 7 years, one-and 3-year survival rate of the recipients was 92.9% and 78.3% respectively. Among these 28 recipients, 4 cases had the graft renal dysfunction early post-operation: One died and 3 recovered through consecutive therapy. One case received re-transplantation of the liver 3 months after the first due to the relevant complications and then recovered. During this period, no impact on the renal function occurred. Eleven cases had pulmonary infection post-operation, and 1 died. No acute rejection occurred.Conclusion Combined liver-kidney transplantation is the effective treatment to the patients with end stage liver disease complicated with renal dysfunction. Suitable case selection and perfect operation timing were the key points to the success of combined liver-kidney transplantation.
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Objective To analyze the curative effect of simultaneous liver and kidney transplantation (SLKT) for patients with end-stage liver and kidney diseases and liver cirrhosis patients with hepatorenal syndrome.Methods All SLKTs (n=21) performed at our center from January 1999 to December 2010 were reviewed and SLKT outcomes were compared with those of kidney transplantation (KT) (n=609) and liver transplantation (LT) (n=133) performed during the same period.Results There were 3 deaths due to infection 2 weeks, 6 months and 5 years respectively after operation. One patient died due to multiple organ dysfunction syndrome 2 weeks after operation. One patient was dead 5 years after operation because of rejection. MELD level between SLKT and LT had no significant difference, but serum creatinine in SLKT group was significantly higher than in LT group (516.0±329.9 vs 111.4±138.1 mmol/L, P<0.01). The 1-year acute kidney rejection rate and rate of delayed graft function (DGF) of the kidney had no significant difference between SLKT group (0 vs 9.5 %) and KT group (6 % vs 17.3 %). There was no significant difference in one-, 3- and 5-year patient survival rate between SLKT group (87.7 %, 67.8 % and 67.8 %) and LT group (84.2 %, 73.5 % and 69.4 %).Conclusion SLKT is a safe and effective treatment for end-stage liver and kidney diseases.
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Coexisting end stage liver disease (ESLD) and end stage renal disease (ESRD) for a patient on dialysis is a standard indication for a combined liver-kidney transplantation (CLKT). A survival advantage after CLKT has been verified in liver transplant candidates with significant kidney dysfunction due to chronic kidney disease (CKD) or acute kidney injury (AKI). The severity (glomerular filtration rate (GFR) 2.0 mg/dL or who are on dialysis. Because of the immunological modulation effect of the liver graft, post-transplant CLTX results in a lower incidence of acute rejection and higher long-term censored graft survival rate in kidney transplant recipients. Despite the advantages of CLKT, the CLKT waiting list is extremely rare in Korea (0.80%, 67/3,717, from recent Korean Network for Organ Sharing (KONOS) data on March 2010). The narrow indications for CLKT (only ESRD candidates on dialysis are accepted for CLKT) and inferior ranking of CLKT for kidney allocation is a pitfall of the multi-organ allocation rule in KONOS.
Subject(s)
Humans , Acute Kidney Injury , Creatinine , Dialysis , End Stage Liver Disease , Filtration , Graft Survival , Imidazoles , Incidence , Kidney , Kidney Failure, Chronic , Korea , Liver , Nitro Compounds , Rejection, Psychology , Renal Insufficiency, Chronic , Survival Rate , Transplants , Waiting ListsABSTRACT
Objective To investigate the potential role of tumor necrosis factor-alpha (TNF-?) in apoptosis after combined liver and kidney transplantation in rats. Methods Eighty rats which had combined liver and kidney transplantation were randomly paired, were divided into study group (n=20) and control group (n=20). 40 ml of 4 ℃ sodium chloride and anti-TNF-? monoclonal antibody (30 ml was infused from portal veins to donated livers and 10 ml from renal arteries to donated kidneys) were infused to the study group (0.1 mg/kg weight),and the same quantity of 4 ℃ sodium chloride was infused the control group. Venous blood was drew at different phases after the transplantations to detect the function of kidney and liver. The level of TNF-? and the cell apoptosis were detected in the transplanted tissues of liver and kidney by ELISA and terminal deoxynucleotidy transferase mediated dTUP-biotin nick-end labeling (TUNEL). Results The levels of AST, ACT, Cr and BUN in the study group were significantly lower than those of the control group at the same phases (P