Ekser Burcin, Mangus Richard S, Fridell W, Kubal Chandrashekhar A, Nagai Shunji, Kinsella Sandra B, Bayt Demetria R, Bell Teresa M, Powelson John A, Goggins William C, Tector A Joseph
*Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, IN†Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN‡Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.
Ann Surg. 2017 May;265(5):1000-1008. doi: 10.1097/SLA.0000000000001752.
The aim of this study was to compare the outcomes of simultaneous and delayed implantation of kidney grafts in combined liver-kidney transplantation (CLKT).
Delayed function of the renal graft (DGF), which can result from hypotension and pressor use related to the liver transplantation (LT), may cause worse outcomes in CLKT.
A total of 130 CLKTs were performed at Indiana University between 2002 and 2015 and studied in an observational cohort study. All kidneys underwent continuous hypothermic pulsatile machine perfusion until transplant: 69 with simultaneous kidney transplantation (KT) (at time of LT, group 1) and 61 with delayed KT (performed at a later time as a second operation, group 2). All patients received continuous veno-venous hemodialysis during the LT. Propensity score match analysis in a 1:1 case-match was performed.
Mean kidney cold ischemia time was 10 ± 3 and 50 ± 15 hours, for groups 1 and 2 (P < 0.0001), respectively. The rate of DGF was 7.3% in group 1, but no DGF was seen in group 2 (P = 0.0600). Kidney function was significantly better in group 2, if the implantation of kidneys was delayed >48 hours (P < 0.01). Patient survival was greater in group 2 at 1 year (91%), and 5 year (87%) post-transplantation (P = 0.0019). On multivariate analysis, DGF [hazard ratio (HR), 165.7; 95% confidence interval (CI), 9.4-2926], extended criteria donor kidneys (HR, 15.9; 95% CI 1.8-145.2), and recipient hepatitis C (HR, 5.5; 95% CI 1.7-17.8) were significant independent risk factors for patient survival.
Delayed KT in CLKT (especially if delayed >48 h) is associated with improved kidney function with no DGF post-KT, and improved patient and graft survival.
本研究旨在比较肝肾联合移植（CLKT）中肾移植同期植入和延迟植入的效果。
肾移植延迟功能（DGF）可能由肝移植（LT）相关的低血压和升压药使用引起，这可能导致CLKT出现更差的结果。
2002年至2015年期间，印第安纳大学共进行了130例CLKT，并在一项观察性队列研究中进行了分析。所有肾脏在移植前均接受持续低温脉动机器灌注：69例为同期肾移植（KT）（在LT时进行，第1组），61例为延迟KT（在稍后时间作为第二次手术进行，第2组）。所有患者在LT期间均接受持续静脉-静脉血液透析。进行了1:1病例匹配的倾向评分匹配分析。
第1组和第2组的平均肾脏冷缺血时间分别为10±3小时和50±15小时（P<0.0001）。第1组的DGF发生率为7.3%，但第2组未观察到DGF（P=0.0600）。如果肾脏植入延迟>48小时，第2组的肾功能明显更好（P<0.01）。第2组在移植后1年（91%）和5年（87%）的患者生存率更高（P=0.0019）。多因素分析显示，DGF[风险比（HR），165.7；95%置信区间（CI），9.4-2926]、扩展标准供体肾脏（HR，15.9；95%CI 1.8-145.2）和受者丙型肝炎（HR，5.5；95%CI 1.7-17.8）是患者生存的显著独立危险因素。
CLKT中延迟KT（尤其是延迟>48小时）与改善肾功能、KT后无DGF以及改善患者和移植物生存率相关。
