Gastrolearning XVIII lezione Il trapianto combinato di fegato e rene - Prof. D. Pinna (Università di Bologna).

1. INDICAZIONI AL TRAPIANTO
COMBINATO DI FEGATO-RENESezione di Nefrologia
Sezione di Nefrologia
U.O. Chirurgia generale e dei Trapianti Prof. A.D. Pinna
Azienda Ospedaliera Policlinico S.Orsola-Malpighi
Università degli Studi di Bologna

2. Liver-Kidney Transplantation
Background
Nadim M.K.et al., Am. J. Transpl. 2012

3. Liver-Kidney Transplantation
Background
Nadim M.K.et al., Am. J. Transpl. 2012

4. Liver-Kidney Transplantation
Background
Nadim M.K.et al., Am. J. Transpl. 2012

5. Liver-Kidney Transplantation
Background
Nadim M.K.et al., Am. J. Transpl. 2012

6. Liver-Kidney Transplantation
Background
Nadim M.K.et al., Am. J. Transpl. 2012

7. Liver-Kidney Transplantation
Background
Fong T.L. et al., Transplantation. 2012

8. Liver-Kidney Transplantation
Background
Martin E.L.,et al., Liver Transpl. 2012

9. Liver-Kidney Transplantation
Background
Eason J.,et al., Am. J. Transpl. 2008

10. Liver-Kidney Transplantation
Background
• Mainly the indication to combined liver-kidney transplantation
is a liver disease that caused also a chronic kidney insufficiency
(Serum creatinine > 2 mg/dL)
• The most frequent indications are: liver cirrhosis virus or alchol
related, policystic disease, genetics or metabolics disorders,
cholestatic disease.
• As a result, liver-kidney transplantation is considered a safe
procedure and the immunosuppressive regimen that should be
adopted is debated
• Recipient selection is critical especially within MELD-based
systems

11. Liver-kidney transplantation
Aim
To report a series of liver-kidney transplantation
for adult recipients performed at a single center
and to evaluate the different results considering
indications and the impact of different
immunosuppressive strategy

12. Liver-kidney transplantation
Aim

13. Liver-KidneyTransplantation
Methods: study period
• Retrospective study with prospectively collected data
• Period: January 1997 – December 2012
• 47 Liver-Kidney transplantations in adult patients
• 40 (84.4%) whole liver
• 7 (15.6%) split liver grafts
5 Right extended – 2 Left lateral segments
• Only AB0-compatible donors were used

14. • Among 57 listed patients for combined liver-kidney
transplant:
4747 (82%) were effectively transplanted(82%) were effectively transplanted
5 (9.1%) dead on waiting list5 (9.1%) dead on waiting list
3 (5.5%) were in stand-by3 (5.5%) were in stand-by
1 (1.8%) was on the waitng list1 (1.8%) was on the waitng list
1 (1.8%) refused the combined liver-kidney transplant1 (1.8%) refused the combined liver-kidney transplant
Study population

15. Liver Kidney transplantations
Study population
MELD

16. Liver-Kidney Transplantation
Results: Recipient characteristics
• Mean age of recipient 49.91 ± 9.87 (14-65)
• Sex of recipient (M/F) 27 (57%) / 20 (43%)
• Mean MELD at time of LKT 22.16 ± 7.39 (11-42)
• Mean Time on waiting list (months) 8.11 ± 9.75 (0.1- 35.76)
• Follow-up (years) 3.74 ± 3.01 (0.01- 9.87)

17. Liver-Kidney Transplantation
Results: Recipient characteristics
• Serum creatinine at listing mg/dL 4.87 ± 2.89
• GFR at listing 25.38 ± 19.58
• Serum creatinine at time of LKTx 4.48 ±2.49
• GFR at time of LKTx 24.72 ± 18.5
• Dialysis at time of LKTx 23/47

18. Liver-Kidney Transplantation
Results: Outcome

19. Liver-Kidney Transplantation
Results: Immunosuppressive regimen
• Ciclosporine (Neoral) 5/47
+
• Tacrolimus (Prograf) 42/47
• Induction with Alemtuzumab (Campath)
(0.3 mg/kg) on day 0 and day 7 13/42
• Change of immunosuppresive therapy:
- Sirolimus (Rapamune) 5/47 (11%)
- MMF (Cellcept) 9/47 (20%)
- No change 33/47 (69%)
Steroids

20. Liver Kidney transplantation
Results: Complications
Infections 17 (37.8%)
Acute cellular liver rejections
Kidney rejection
3 / 47 (6%)
4 / 47 (8%)
De novo cancer:
- Kidney cancer
- Larynx cancer
- Skin cancer
3 /47 (6%)
1
1
1

21. Liver-Kidney Transplantation
Results: donor features
Age (years) 41.9 ± 17.3 (13 – 81)
Cause of death
Trauma 16 (36%)
Cerebrovascular 21 (47%)
Other 8 (17%)
HBcore positive 8 (17%)
HCV positive 1 (2%)
Liver mean ischemia time (min.)
Kidney mean ischemia time (min.)
376 ± 83.99 (235-644)
761.35 ± 168.24 (480-1380)

22. Liver-Kidney Transplantation
Results: Indications
Indication for Liver-Kidney transplantation:
Liver disease
Policistyc disease 17 (36%)
Cirrhosis
HCV
HBV
Alchol
11(22%)
5 (11%)
4 (9%)
Genetic/metabolic 6 (13%)
Cholestatic 2 (4%)
HCC on cirrhosis 2 (4%)

23. Liver-Kidney Transplantation
Results: Indications
Indication for Liver-Kidney transplantation:
Kidney disease
Policistyc disease 16 (36%)
End Stage Kidney disease 8 (18%)
GN IgA 3 (6.6%)
GNC 3 (6.6%)
GSFS 2 (4%)
Interstitial nephrites 2 (4%)
Vascular disease (hypertension+diabetes) 2 (4%)
Amyloidotic nephropathy 1 (2.2%)
Cryoglobulinemic syndrome 1 (2.2%)
Hyperoxaluria type 1 1 (2.2%)
Glicogenosis 1 (2.2%)
Unknown disease 5 (11%)

24. Liver Kidney Transplantations
Results: post-op. complications
Vascular complic. 3 (6%)
Biliary compl. 7 (15%)
Neurological compl. 3 (6%)
Surgical reoperations 7 (15%)
2 Liver re-TX: - HA thrombosis
- Small for size syndrome
2 Kidneys transplantectomy: - 2 R. V. thrombosis
1 Splenectomy for platelets disorders
2 Nephrectomy of native kidney
Post-operative Dialysis 7 (15%)

25. Liver-Kidney Transplantation
Results: outcome
100%
66.7%
80%
60%
Del Gaudio M. et al, Transpl. Proc. 2013 IN PRESS

26. Liver-Kidney Transplantation
Results: outcome
69.2%
85.7%
Del Gaudio M. et al, Transpl. Proc. 2013 IN PRESS

27. Liver-Kidney Transplantation
Results: outcome
P=0.04
Tacrolimus
Through level
ng/mL
Del Gaudio M. et al, Transpl. Proc. 2013 IN PRESS

28. Liver-Kidney Transplantation
Results: outcome
65.6%
75%
Del Gaudio M. et al, Transpl. Proc. 2013 IN PRESS

29. Conclusions
• Liver-kidney transplantation is a safe and effective procedure.
• Even in the MELD era with cadaveric marginal donors, the
transplantation rate of listed patients is high with acceptable dropout from
the waiting list
• The standard immunosuppressive regimen based on Tacrolimus and
steroids can be ameliorated by induction therapy with Alemtuzumab
(Campath).
• An adjusted MELD score for this kind of recipients can be shortening the
time on waiting list