Orthotopic liver transplantation is now the best therapeutic option for patients with chronic liver failure [1]. Liver transplant is now a routine surgery performed in numerous medical centers throughout the world. Till now about 600 liver transplants have been performed in the Indraprastha Apollo Hospital, New Delhi. Combined liver kidney transplantation (CKLT) is the treatment for end-stage liver and kidney diseases. Combined liver kidney transplantation from living donors is performed in very few centers. Not many cases of Living donor combined Liver Kidney transplantation has been described in the literature. Here we report the clinical experience of our first living donor combined liver kidney transplantation (kidney after liver) in patient with end-stage liver disease (ESLD) and end stage renal failure (ESRD). Liver and kidney graft has been harvested from two living related donors.

1. Anaesthesia for Living Donor Combined Liver Kidney
Transplantation

2. Case Report
INTRODUCTION
With advances in transplantation, multiorgan
transplantation has become a treatment of choice for end-
stage organ failure which can not be reversed with other
modalities. In 1984, Margreiter, et al [2] performed the
first combined kidney and liver transplantation. Patients
with renal failure after liver transplantation have a
particularly poor prognosis. Therefore, in the setting of
end-stage renal disease requiring dialysis or severe renal
insufficiency that will not improve after liver replacement,
combined liver-kidney transplantation (CKLT) is the
preferred approach.
We report such a case below.
CASE REPORT
A44 year old man presented to theApollo Hospital, New
Delhi, with history of jaundice for three and half years,
fatigue and fever for one year, decreased urine output for two
weeks. He complained of one episode of hematemesis 3 days
back. Patient gave history of alcohol abuse and abstinence
for more than two years. Ultrasound abdomen showed
cirrhosis of liver, ascites with portal hypertension. Other
investigations are shown in (Table 1). During the course in
hospital he was put on hemodialysis. He was managed
conservatively for hematemesis & deteriorating level of
consciousness. In spite of best medical efforts his condition
did not improve. Case was discussed in multidisciplinary
ANAESTHESIA FOR LIVING DONOR COMBINED LIVER KIDNEY TRANSPLANTATION
Sanjeev Aneja* and Sharadkumar Upwar**
*Senior Consultant in Anesthesia, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India,
**Consultant Anesthetist, Apollo Hospitals, E-2, Sector 26, Noida 201 302, India.
Correspondence to: Dr Sanjeev Aneja, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India.
E-mail: sanjeevaneja@hotmail.com
Orthotopic liver transplantation is now the best therapeutic option for patients with chronic liver failure [1]. Liver
transplant is now a routine surgery performed in numerous medical centers throughout the world. Till now
about 600 liver transplants have been performed in the Indraprastha Apollo Hospital, New Delhi. Combined
liver kidney transplantation (CKLT) is the treatment for end-stage liver and kidney diseases. Combined liver
kidney transplantation from living donors is performed in very few centers. Not many cases of Living donor
combined Liver Kidney transplantation has been described in the literature. Here we report the clinical
experience of our first living donor combined liver kidney transplantation (kidney after liver) in patient with end-
stage liver disease (ESLD) and end stage renal failure (ESRD). Liver and kidney graft has been harvested
from two living related donors.
Keywords: Combined liver kidney transplantation, Living related liver kidney transplantation.
liver transplantation meeting and live related combined
liver and kidney transplantation was considered. Family of
patient was counseled, they were given all therapeutic
options i.e. combined vs sequential combined liver kidney
transplantation. Family opted for combined liver kidney
Table1. Laboratory investigations
Hb: 8.8 gm% Sr Sodium- 141 mEq/lit
TLC- 12000/ cmm Sr. Potassium- 3.7 mEq/lit
Platelet- 64000/ cmm Sr. Calcium- 9.0
PT- 26.8/ 11.8 sec Sr. Phosphorus- 6.9
INR- 2.3 AST/ALT- 54/26 U/L
PTT- 34.3/33 Creatinine clearance-27 mL/
min
Urea- 144 Direct bilirubin -2.4mg/dL
Creatinine- 4.1 Alkaline phosphatase- 63 U/L
HBsAg- Negative Urine protein/creatinine ratio
6.3
Anti HCV- Positive Urine spot sodium 40 mEq
HIV I, II- Negative Fibrinogen level- 75 mg/dL
CMV IgG- Reactive FDP- >20 microIU/mL
ABG on roomAir-
pH 7.38, pCo228
mmHg, pO2 89
mmHg, HCO3 18,
BE 0.1, O2 sat 95%
Apollo Medicine, Vol. 8, No. 2, June 2011 142

3. Case Report
143 Apollo Medicine, Vol. 8, No. 2, June 2011
transplant. Two different donors in the family were willing
to share their organs with the patient. Modified Child-Pugh
classification score is 14-Grade C (Table 2) Model for End
Stage Liver Disease (MELD) Score: 40 points (Sr Bilirubin
16 mg/dL, INR 2.3, Sr Creatinine 4.1+ history of dialysis).
Complete cardiac evaluation was done: Dobutamine
stress echo was negative for ischemia, LVEF 65%,
pulmonary artery systolic pressure 35mmHg.
He underwent hemodialysis a day before surgery. Body
weight of the patient was 60 kg. He was on antibiotics,
antifungal and proton inhibitors. Blood products were
arranged as per transplant protocol (10 units of PRC, 15,
units of FFP, 2 single donor plasma, 2 single donor platelets
and 4 cryoprecipitate were arranged). Hemodialysis
machine was arranged to be made available in the theatre
for intraoperative dialysis if needed.
On the day of surgery patient was shifted to designated
operating room with all facilities for warming & infusing
large volume of fluid quickly. All monitors were applied
as per standard guidelines.
Left redial artery was cannulated with 20G cannula
under local anesthesia. After preoxgenation rapid
sequence induction was done with inj fentanyl 300 mcg (5
mcg/kg), inj propofol 120 mg (2 mg/kg), and inj
suxamethonium 75 mg (1.5 mg/kg). Trachea was
intubated with 8.5 mm internal diameter size endotracheal
tube. Right internal jugular vein cannulated with triple
lumen catheter and 8F size sheath. Pulmonary artery
catheter was inserted for pulmonary artery pressure
monitoring. For intraoperative dialysis right subclavian
vein cannulated with dialysis catheter. Anaesthesia was
maintained with oxygen, air, isoflurane, inj Atracurium
infusion 0.5mg/kg/hr, fentanyl infusion 2 mcg/kg/hr.
Patient was monitored using electrocardiogram (ECG),
ST segment analyzer, pulse oximeter, capnometer, central
venous pressure, pulmonary artery pressure, cardiac
output, arterial blood pressure, temperature and urine
output. Core body temperature was maintained by
convective warmer, warming mattress, warm intravenous
fluids using HOTLINE (Rapid Infusion). Coagulation
parameters were observed with hourly Prothombin time
(PT), INR, aPTT and thromboelastograph (TEG). Hourly
ABG, Hb, PCV, platelet count was done. Based on these
reports blood and blood products were administered as per
departmental protocol. (To keep Hb ≥8 gm%, INR 1.5-1.8,
Platelets as per TEG and surgical bleeding).
At the end of dissection phase hemodialysis was
started to correct metabolic acidosis and to correct fluid
status, to make the ideal conditions for new liver. Right
lobe liver graft of the donor transplanted orthotopically.
Patient tolerated the anhepatic and reperfusion phase well.
Hypotension was treated with nor-adrenaline infusion,
and boluses of phenylepherine. After the successful
completion of hepatic artery anastomosis the donor kidney
was harvested from another donor and transplanted extra
peritoneally in left iliac fossa. Patient showed good liver
and kidney graft function on the table as indicated by bile
production, good urine output and correction of metabolic
acidosis.
The total operative blood loss was 2500 mL and
patient received 12 units of packed red cells.
Postoperatively patient was monitored in intensive
care unit. He was on elective mechanical ventilation and
trachea extubated 10 hours postoperatively. For
postoperative pain inj morphine given 3 mg intravenous
on PRN basis. Immunosuppressant regimen includes inj
methyl prednisone, tacrolimus (pan graf) and
mycophenolate mofetil (cellcept). Liver and kidney graft
function has been assessed by INR and Sr Creatinine (Fig
1). No episode of acute rejection was encountered.
Postoperative course was uneventful and patient was
discharged on 20th day postoperatively.
DISCUSSION
The first liver combined liver kidney transplantation
(CLKT) was reported by Margreiter, et al [2] in 1984.
Fig 1. Postoperative liver and kidney graft function.
Table 2. Child-pugh classification
Parameter Points
Ascites Moderate 3
Bilirubin 16 mg/dL 3
Albumin 2.3 gm/dL 3
Prothmbin time (INR) 26.8 (2.3) 3
Encephalopathy Grade 2 2

4. Apollo Medicine, Vol. 8, No. 2, June 2011 144
Case Report
Several authors [3-5] subsequently demonstrated the
feasibility and safety of combined transplantation and
favorable outcome in patients with end stage liver disease
associated with renal failure. Most of these CLKT are
cadaveric and living related combined liver kidney
transplantation is very few in number [6]. This is first
CLKT in our series of 500 liver transplantations.
There is a debate on indications for CLKT and whether
hepatorenal syndrome is an indication for CLKT [7, 8].
The Consensus Conference on Simultaneous Liver Kidney
Transplantation [ 9] agreed on the premise that patients
with following parameters should be an indication for
combined liver kidney transplantation (CLKT) (i) ESRD
patients with cirrhosis and symptomatic portal
hypertension or hepatic vein wedge pressure with gradient
greater than 10 mm Hg; (ii) patients with ESLD and chronic
kidney disease with GFR ≥30 mL/min; (iii) patients with
acute kidney injury(AKI) including hepatorenal
syndrome(HRS) with creatinine ≥2.0 mg/dL and dialysis
≥8 weeks; and (iv) patients with ESLD and evidence of
chronic kidney disease(CKD) and kidney biopsy
demonstrating >30% glomerulosclerosis or 30% fibrosis.
The operation is considered in three phases. The
preanhepatic phase is when the liver is mobilized, the
anhepatic phase when the liver is removed and the third or
neohepatic phase is when the new liver graft is reperfused
and the operation completed. Each phase requires careful
consideration by the anaesthesiologist.
From a surgical - technical point a combined liver and
kidney transplantation is usually not more complicated than
a liver transplant; however the procedure is of course more
time consuming than a regular liver transplant. The liver is
transplanted first followed by the kidney from another
donor. The risk of intraoperative and post operative
bleeding must be considered and the risk of acute tubular
necrosis post-transplant. This risk should theoretically not
be higher than after any kidney transplantation but some
sort of kidney assisting device i.e., hemodialysis should be
used during the liver transplant in order to optimize the
fluid and electrolyte balance i.e., potassium and circulatory
status.The timing of dialysis may be at the end of dissection
phase to control metabolic disturbances during anhepatic
phase and to maintain good internal environment before the
liver graft anastomosis. Higher blood pressure should be
maintained to ensure the perfusion of transplanted kidney.
Timing to procure donor kidney should be at the end of
hepatic artery anastomosis.
Post-transplant a nonnephrotoxic immunosuppressive
regimen or a regimen with low nephrotoxic potential
should preferably be used [10].
CONCLUSION
Anesthesia considerations for liver transplantation
include the management of severely deranged physiology,
pharmacology, and biochemistry, as all organ systems may
be affected adversely by the failing liver. A close working
relationship between all members of the operating team is
necessary for the success of the program. The
development of such teams in major transplant centers has
resulted in a marked reduction in the morbidity and
mortality of this procedure and a concomitant reduction in
the cost.
This case shows a good result of living donation from
different donor and combined liver kidney transplantation
in patient with cirrhosis of liver and kidney failure.
REFERENCES
1. Starzl TE, Iwatsuki S, Van Thiel DH, et al. Evolution of
liver transplantation. Hepatology 1982; 2: 614-636.
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Niederwieser D, Judmaier G, W Vogel. Combined liver
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