Simultaneous Liver-Kidney Transplant: Too Many or Just Enough?

For liver transplant candidates with advanced kidney dysfunction, simultaneous liver-kidney (SLK) transplantation is an important option. As the incidence of severe kidney dysfunction has increased over the past decade, so have the numbers of SLK transplants. This has engendered controversy within the transplant community because SLK transplants draw deceased donor kidneys from the kidney transplant candidate pool. Because kidney recovery after liver transplant alone (LTA) is difficult to predict, indications for SLK are not precisely defined. Candidates with hepatorenal syndrome can have kidney recovery after as much as 12 weeks on dialysis, whereas those with CKD may have early ESRD after LTA because of perioperative events and calcineurin inhibitor exposure. Although large observational studies generally show slightly improved survival in SLK recipients compared with LTA, inferences from these studies are limited by selection biases. Therefore, a true survival benefit of SLK in candidates without ESRD is still unproved. Although selection practices vary, generally LTA candidates have more kidney dysfunction because of hepatorenal syndrome and acute kidney injury, whereas SLK candidates have less severe liver disease and more CKD or ESRD. The debate over appropriate SLK is primarily one of the optimal kidney utilization vs the best interests of individual liver transplant candidates.