Parajuli Sandesh, Hidalgo Luis G, Foley David
Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States.
Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States.
Front Transplant. 2022 Nov 1;1:991546. doi: 10.3389/frtra.2022.991546. eCollection 2022.
Simultaneous liver and kidney (SLK) transplantation is considered the best treatment modality among selected patients with both chronic kidney disease (CKD) and end-stage liver disease (ESLD). Since the first SLK transplant in 1983, the number of SLK transplants has increased worldwide, and particularly in the United States since the implementation of the MELD system in 2002. SLK transplants are considered a relatively low immunological risk procedure evidenced by multiple studies displaying the immunomodulatory properties of the liver on the immune system of SLK recipients. SLK recipients demonstrate lower rates of both cellular and antibody-mediated rejection on the kidney allograft when compared to kidney transplant-alone recipients. Therefore, SLK transplants in the setting of preformed donor-specific HLA antibodies (DSA) are a common practice, at many centers. Acceptance and transplantation of SLKs are based solely on ABO compatibility without much consideration of crossmatch results or DSA levels. However, some studies suggest an increased risk for rejection for SLK recipients transplanted across high levels of pre-formed HLA DSA. Despite this, there is no consensus regarding acceptable levels of pre-formed DSA, the role of pre-transplant desensitization, splenectomy, or immunosuppressive management in this unique population. Also, the impact of post-transplant DSA monitoring on long-term outcomes is not well-studied in SLK recipients. In this article, we review recent and relevant past articles in this field with a focus on the immunological risk factors among SLK recipients, and strategies to mitigate the negative outcomes among them.
肝肾联合移植（SLK）被认为是部分同时患有慢性肾脏病（CKD）和终末期肝病（ESLD）患者的最佳治疗方式。自1983年首例SLK移植以来，全球范围内SLK移植数量不断增加，尤其是自2002年实施终末期肝病模型（MELD）系统后，美国的SLK移植数量增长明显。多项研究表明肝脏对SLK受者免疫系统具有免疫调节特性，因此SLK移植被认为是一种免疫风险相对较低的手术。与单纯肾移植受者相比，SLK受者肾移植发生细胞介导和抗体介导排斥反应的发生率较低。所以，在许多中心，对于已存在供者特异性HLA抗体（DSA）的患者进行SLK移植是一种常见做法。SLK的接受和移植仅基于ABO血型相容性，而很少考虑交叉配型结果或DSA水平。然而，一些研究表明，对于移植时预先存在高水平HLA DSA的SLK受者，排斥反应风险增加。尽管如此，对于预先存在的DSA的可接受水平、移植前脱敏、脾切除术或免疫抑制管理在这一特殊人群中的作用，目前尚无共识。此外，移植后DSA监测对SLK受者长期预后的影响也尚未得到充分研究。在本文中，我们回顾了该领域近期及过去的相关文章，重点关注SLK受者的免疫风险因素，以及减轻其中不良结局的策略。
