Lunsford Keri E, Bodzin Adam S, Markovic Daniela, Zarrinpar Ali, Kaldas Fady M, Gritsch Hans Albin, Xia Victor, Farmer Douglas G, Danovitch Gabriel M, Hiatt Jonathan R, Busuttil Ronald W, Agopian Vatche G
*Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA †Department of Biomathematics, David Geffen School of Medicine at UCLA, Los Angeles, CA ‡Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA §Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, CA ¶Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
Ann Surg. 2017 May;265(5):1016-1024. doi: 10.1097/SLA.0000000000001801.
We sought to evaluate outcomes and predictors of renal allograft futility (RAF-patient death or need for renal replacement therapy at 3 months) after simultaneous liver-kidney transplantation (SLKT).
Model for End-Stage Liver Disease (MELD) prioritization of liver recipients with renal dysfunction has significantly increased utilization of SLKT. Data on renal outcomes after SLKT in the highest MELD recipients are scarce, as are accurate predictors of recovery of native kidney function. Without well-established listing guidelines, SLKT potentially wastes renal allografts in both high-acuity liver recipients at risk for early mortality and recipients who may regain native kidney function.
A retrospective single-center multivariate regression analysis was performed for adult patients undergoing SLKT (January 2004 to August 2014) to identify predictors of RAF.
Of 331 patients dual-listed for SLKT, 171 (52%) expired awaiting transplant, 145 (44%) underwent SLKT, and 15 (5%) underwent liver transplantation alone. After SLKT, 39% experienced delayed graft function and 20.7% had RAF. Compared with patients without RAF, RAF recipients had greater MELD scores, length of hospitalization, intraoperative base deficit, incidence of female donors, kidney and liver donor risk indices, kidney cold ischemia, and inferior overall survival. Multivariate predictors of RAF included pretransplant dialysis duration, kidney cold ischemia, kidney donor risk index, and recipient hyperlipidemia.
With 20% short-term loss of transplanted kidneys after SLKT, our data strongly suggest that renal transplantation should be deferred in liver recipients at high risk for RAF. Consideration for a kidney allocation variance to allow for delayed renal transplantation after liver transplantation may prevent loss of scarce renal allografts.
我们试图评估同期肝肾联合移植（SLKT）后肾移植无用（RAF，即患者在3个月时死亡或需要肾脏替代治疗）的结局及预测因素。
对合并肾功能不全的肝移植受者采用终末期肝病模型（MELD）进行优先排序，显著增加了SLKT的应用。关于最高MELD评分受者接受SLKT后的肾脏结局数据稀缺，天然肾功能恢复的准确预测因素也同样稀缺。由于缺乏完善的登记指南，SLKT可能会在有早期死亡风险的高急症肝移植受者以及可能恢复天然肾功能的受者中浪费肾移植器官。
对2004年1月至2014年8月期间接受SLKT的成年患者进行回顾性单中心多因素回归分析，以确定RAF的预测因素。
在331例同时登记等待SLKT的患者中，171例（52%）在等待移植期间死亡，145例（44%）接受了SLKT，15例（5%）仅接受了肝移植。SLKT后，39%的患者出现移植肾功能延迟恢复，20.7%的患者发生RAF。与未发生RAF的患者相比，发生RAF的受者MELD评分更高、住院时间更长、术中碱缺失更大、女性供者发生率更高、肾脏和肝脏供者风险指数更高、肾脏冷缺血时间更长，总体生存率更低。RAF的多因素预测因素包括移植前透析时间、肾脏冷缺血时间、肾脏供者风险指数和受者高脂血症。
SLKT后有20%的移植肾在短期内丧失功能，我们的数据强烈表明，对于有RAF高风险的肝移植受者应推迟肾移植。考虑进行肾脏分配差异调整，以便在肝移植后延迟肾移植，可能会避免稀缺肾移植器官的损失。
