Cui Jiawei, Spann Ashley, Shingina Alexandra, Schaefer Heidi, Slaughter James C, Matsuoka Lea, Alexopoulos Sophoclis, Izzy Manhal
Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Clin Transplant. 2022 Dec;36(12):e14812. doi: 10.1111/ctr.14812. Epub 2022 Oct 5.
Severe renal dysfunction is common among liver transplant (LT) candidates and often prompts simultaneous liver-kidney transplantation (SLKT) consideration. In view of 2017 United Network of Organ Sharing (UNOS) criteria for SLKT, we investigated the likelihood and predictors of renal recovery among patients who met the aforementioned criteria yet received liver transplant alone (LTA).
We retrospectively analyzed relative renal recovery (RRR; increase in eGFR to >30 ml/min) in adult LTA recipients between 1/2009 and 1/2019.
Of 1165 LT recipients, 54 met 2017 UNOS criteria, with 37 receiving LTA. RRR occurred in 84% of LTA recipients, none of whom had pre-LT eGFR <20 ml/min. Sustained RRR (>180 days) occurred in 43% of patients. While prolonged pre-LT severe renal impairment (eGFR <30 ml/min) predicted failure to have sustained RRR (HR .19 per 90-day, CI .04-.87, p < .005), having an eGFR measurement of >30 ml/min within 90 days pre-LT (HR 5.52, CI 1.23-24.79, p .01) associated with achieving sustained RRR. Sustained RRR was protective against the composite outcome of renal replacement therapy, kidney transplant, and death (HR .21, p .01).
LT candidates who meet 2017 UNOS criteria for SLKT yet undergo LTA can still have relative renal recovery post-LT, exceeding 80% on short-term follow-up and 40% on long-term follow-up. eGFR trends within 90 days pre-LT can predict sustained renal recovery, which appears protective of adverse outcomes. These recovery rates advocate for applying the more restrictive criteria for SLKT outlined in this article and increasing utilization of the safety net (SN) policy for those who do not meet the proposed criteria.
严重肾功能不全在肝移植（LT）候选者中很常见，常促使人们考虑同时进行肝肾联合移植（SLKT）。鉴于2017年器官共享联合网络（UNOS）的SLKT标准，我们调查了符合上述标准但仅接受肝移植（LTA）的患者肾功能恢复的可能性及预测因素。
我们回顾性分析了2009年1月至2019年1月期间成年LTA受者的相对肾功能恢复情况（RRR；估算肾小球滤过率（eGFR）增加至>30 ml/分钟）。
在1165例LT受者中，54例符合2017年UNOS标准，其中37例接受了LTA。84%的LTA受者出现了RRR，其中没有患者在肝移植前eGFR<20 ml/分钟。43%的患者出现了持续RRR（>180天）。虽然肝移植前严重肾功能损害持续时间较长（eGFR<30 ml/分钟）预示着无法实现持续RRR（每90天风险比为0.19，可信区间为0.04 - 0.87，p<0.005），但在肝移植前90天内eGFR测量值>30 ml/分钟（风险比为5.52，可信区间为1.23 - 24.79，p = 0.01）与实现持续RRR相关。持续RRR可预防肾替代治疗、肾移植和死亡的复合结局（风险比为0.21，p = 0.01）。
符合2017年UNOS的SLKT标准但接受LTA的LT候选者在肝移植后仍可实现相对肾功能恢复，短期随访中超过八成，长期随访中超过四成。肝移植前90天内的eGFR趋势可预测肾功能的持续恢复，这似乎对不良结局具有保护作用。这些恢复率支持采用本文所述的更严格的SLKT标准，并提高对不符合提议标准者的安全网（SN）政策的利用率。
