Brown R S, Lombardero M, Lake J R
Department of Medicine, University of North Carolina, Chapel Hill 27599, USA.
Transplantation. 1996 Dec 27;62(12):1788-93. doi: 10.1097/00007890-199612270-00018.
Renal insufficiency (RI) is a common finding with end-stage liver disease. RI is generally not regarded as a contraindication to liver transplantation. However, the impact of RI on outcome following transplantation and the role of combined liver-kidney transplant are not well understood. The effect of RI on patients with fulminant hepatic failure (FHF) or chronic liver disease (cirrhosis) was investigated using the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Liver Transplantation Database. Patients were analyzed based on the presence of RI, defined as creatinine >1.6 mg/dl, or on dialysis. Patients undergoing liver-kidney transplantation were analyzed separately. For patients with FHF, the RI group had a lower patient survival rate at 1 year (50% vs. 83%, P=0.04) and tended to have a lower graft survival rate (50% vs. 71%). Stay in the intensive care unit (ICU) was prolonged in the RI group but hospital stay was not. Among patients with cirrhosis, RI did not affect patient survival, except for patients on dialysis or those with liver-kidney transplants. One-year patient and graft survival rates were 65% and 60% for the dialysis group, 74% and 70% for the liver-kidney transplant group, 89% and 86% for RI patients not on dialysis, and 89 and 84% for non-RI patients. ICU and hospital stays were prolonged for all of the RI groups compared with the non-RI patients. Patients with RI had higher rates of posttransplant dialysis; however, the differences tended to equalize after 4 weeks. We conclude that RI in FHF and RI requiring dialysis or liver-kidney transplantation in cirrhosis predict lower posttransplant patient and graft survival rates. Patients with RI have longer hospital and ICU stays and an increased need for dialysis, which likely increases the cost of transplantation. Whether liver-kidney transplantation improves outcome and thus represents an appropriate use of cadaver kidneys requires further study.
肾功能不全（RI）是终末期肝病的常见表现。RI一般不被视为肝移植的禁忌证。然而，RI对移植后结局的影响以及肝肾联合移植的作用尚未得到充分了解。利用美国国立糖尿病、消化和肾脏疾病研究所（NIDDK）肝移植数据库，研究了RI对暴发性肝衰竭（FHF）或慢性肝病（肝硬化）患者的影响。根据是否存在RI（定义为肌酐>1.6mg/dl）或是否接受透析对患者进行分析。对接受肝肾联合移植的患者进行单独分析。对于FHF患者，RI组1年时的患者生存率较低（50%对83%，P=0.04），且移植肝生存率也往往较低（50%对71%）。RI组在重症监护病房（ICU）的停留时间延长，但住院时间未延长。在肝硬化患者中，除了接受透析的患者或接受肝肾联合移植的患者外，RI不影响患者生存率。透析组的1年患者和移植肝生存率分别为65%和60%，肝肾联合移植组为74%和70%，未接受透析的RI患者为89%和86%，非RI患者为89%和84%。与非RI患者相比，所有RI组的ICU和住院时间均延长。RI患者移植后透析率较高；然而，4周后差异趋于平衡。我们得出结论，FHF中的RI以及肝硬化中需要透析或肝肾联合移植的RI预示着移植后患者和移植肝生存率较低。RI患者的住院和ICU停留时间更长，透析需求增加，这可能会增加移植成本。肝肾联合移植是否能改善结局，从而合理利用尸体肾，还需要进一步研究。
