Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Am J Transplant. 2012 Nov;12(11):2958-65. doi: 10.1111/j.1600-6143.2012.04177.x. Epub 2012 Jul 3.
Guidelines recommend restricting simultaneous liver-kidney (SLK) transplant to candidates with prolonged dialysis or estimated glomerular filtration rate (eGFR) <30 mL/min/1.73m(2) for 90 days. However, few studies exist to support the latter recommendation. Using Scientific Registry of Transplant Recipients and Medicare dialysis data, we assembled a cohort of 4997 liver transplant recipients from February 27, 2002-January 1, 2008. Serial eGFRs were calculated from serum creatinines submitted with MELD reports. We categorized recipients by eGFR patterns in the 90 days pretransplant: Group 1 (eGFR always >30), Group 2 (eGFR fluctuated), Group 3 (eGFR always <30) and Group 4 (short-term dialysis). For Group 2, we characterized fluctuations in renal function using time-weighted mean eGFR. Among liver-alone recipients in Group 3, the rate of end-stage renal disease (ESRD) by 3 years was 31%, versus <10% for other groups (p < 0.001). In multivariable Cox regression, eGFR Group, diabetes (HR 2.65, p < 0.001) and black race (HR 1.83, p = 0.02) were associated with ESRD. Among liver-alone recipients in Group 2, only diabetics with time-weighted mean eGFR <30 had a substantial ESRD risk (25.6%). In summary, among liver transplant candidates not on prolonged dialysis, SLK should be considered for those whose eGFR is always <30 and diabetic candidates whose weighted mean eGFR is <30 for 90 days.
指南建议将同时进行肝-肾（SLK）移植限制在透析时间延长或估计肾小球滤过率（eGFR）<30 mL/min/1.73m(2) 90 天的患者。然而，很少有研究支持后者的建议。使用 Scientific Registry of Transplant Recipients 和 Medicare 透析数据，我们从 2002 年 2 月 27 日至 2008 年 1 月 1 日，组装了一个包含 4997 例肝移植受者的队列。血清肌酐报告中的 eGFR 从血清肌酐计算。我们根据移植前 90 天的 eGFR 模式对受者进行分类：第 1 组（eGFR 始终>30）、第 2 组（eGFR 波动）、第 3 组（eGFR 始终<30）和第 4 组（短期透析）。对于第 2 组，我们使用时间加权平均 eGFR 来描述肾功能的波动。在第 3 组的单纯肝移植受者中，3 年内终末期肾病（ESRD）的发生率为 31%，而其他组的发生率<10%（p<0.001）。在多变量 Cox 回归中，eGFR 组、糖尿病（HR 2.65，p<0.001）和黑人种族（HR 1.83，p=0.02）与 ESRD 相关。在第 2 组的单纯肝移植受者中，只有时间加权平均 eGFR<30 的糖尿病患者有较高的 ESRD 风险（25.6%）。总之，在未进行长期透析的肝移植候选者中，对于 eGFR 始终<30 的患者和 90 天内加权平均 eGFR<30 的糖尿病候选者，应考虑进行 SLK。
