Outcomes of Combined Liver-Kidney Transplantation - Single Center Experience.

BACKGROUND: There is continuous growth of combined liver-kidney transplantation (CLKTx) numbers with remarkable outcomes, especially among patient with liver cirrhosis and end-stage renal disease. The aim was to present a single center experience. METHODS: Twenty patients (9 males) with a mean age of 48 (range: 20-62) years underwent CLKTx from 2005 to 2022. Indications were polycystic liver and kidney diseases (ADPKD) in 12 cases, cirrhosis due to hepatitis (4 patients), and 1 case of amyloidosis, alcoholic liver disease, nonalcoholic steatosis, and congenital hepatic fibrosis with concomitant glomerulonephritis. After hepatectomy, half of the patients had orthotopic liver transplantation with piggy-back technique, and the other had conventional technique. All but 1 recipient had biliary end-to-end anastomosis. 3 patients had preemptive kidney graft transplantation. 4 underwent simultaneous right-side nephrectomy due to volume of the right kidney. Kidney was transplanted from the separate incision after abdominal closure with typical anastomoses. Tacrolimus, mycophenolate mofetile, basiliximab, and steroids were applied for all recipients. RESULTS: Mean follow-up was 57.7 ± 54 months. No primary non-function of the grafts occurred. Delayed kidney graft function (DGF) occurred in 8 patients. Three-month, 1-year, and 5-year cumulative survival rates were: 90%, 80%, and 72% respectively. None of the patients required retransplantation, and 1 recipient returned to hemodialysis 19 months after transplantation. Preemptive kidney transplantation and simultaneous right-side nephrectomy were not significant for DGF and recipient survival. No deaths within the first year occurred in piggy-back technique. CONCLUSIONS: CLKTx is safe and effective in the treatment of both liver and kidney failure.

Intraoperative dialysis with the use of a mobile dialysis system during liver transplantation.

PURPOSE: Over the last few years, transplant centers have started to use various intraoperative renal replacement therapy (ioRRT) modalities during liver transplantation (LT) in patients with pre-existing renal impairment. Here, we present a study on the safety and clinical outcomes of intraoperative hemodialysis (ioHD) performed using a mobile dialysis system during LT. PATIENTS AND METHODS: We retrospectively analyzed 102 adult patients undergoing LT with ioHD; pre-existing renal failure and/or intraoperative metabolic derangement were ioHD treatment indications. RESULTS: Our study cohort consisted of three groups: LT with preoperative serum creatinine (sCr) â€‹< â€‹2 â€‹mg/dL (Group 1:n â€‹= â€‹22), LT with preoperative sCr ≥2 â€‹mg/dL (Group 2:n â€‹= â€‹73), and simultaneous liver-kidney transplantation (Group 3:n â€‹= â€‹7). Among the procedures, 30% were re-transplantations. The mean calculated Model for End-stage Liver Disease score in Group 2 was 39.2, and 67% of patients were hospitalized in the intensive care unit. Patients in Group 1 were less acutely ill but developed severe intraoperative derangements and, therefore, underwent urgent ioHD intraoperatively. However, it was delayed when compared to Group 2. All groups achieved post-reperfusion potassium levels <4 â€‹mmol/L and a decrease in central venous pressure. No serious procedural complications occurred. Post-reperfusion syndrome occurred in 12.7% of patients. Elevated mortality was likely due to the high illness severity in the cohort. CONCLUSIONS: Performing ioHD with a mobile dialysis system during LT was safe and effective, while being easier to perform than continuous techniques. Its effect on intra- and postoperative outcomes should be addressed in a study with a control group.

Simultaneous Liver-Kidney Transplantation and the Use of Intraoperative Dialysis: A Monocenter Study.

BACKGROUND: Simultaneous liver and kidney transplants (SLKT) represent 1.1% of all liver transplants in Poland. Patients undergoing SLKT experience a longer operation time and concurrent kidney dysfunction may aggravate metabolic derangement associated with the procedure. The benefits of intraoperative dialysis (ioHD) in these patients have not been determined. METHODS: A retrospective observational study of all adult patients undergoing SLKT in our center from January 2009 till December 2016. RESULTS: Study group consisted of 10 patients with End-Stage Kidney Disease (0.9% of all liver transplants): 6 patients treated with ioHD during SLKT (group 1) and 4 patients managed conservatively (group 2). All recipients were on chronic dialysis. The mean calculated Model for End-Stage Liver Disease score was 21 ± 0.9 in group 1 and 30 ± 9.5 in group 2 (P = .009). The mean preoperative serum potassium was 4.7 ± 0,6 mmol/L in group 1 and 3.97 ± 1,02 in group 2. Intraoperative serum potassium levels were comparable between the groups, but the maximum lactate and minimum bicarbonate levels were significantly worse in group 2. Postreperfusion syndrome occurred in no patient. Dialysis circuit clotting occurred in 50% of ioHD. Six patients (2 in group 1) required renal replacement therapy after SLKT; no patient was on dialysis on discharge. Three patients died within 1 year after surgery (2 in group 2). CONCLUSIONS: No patient developed intraoperative hyperkalemia or postreperfusion syndrome. We observed a high frequency of circuit system clotting during ioHD. Clinical benefits of intraoperative hemodialysis during SLKT need to be determined in a larger study.

Intraoperative Dialysis During Liver Transplantation.

BACKGROUND: Orthotopic liver transplantation (LT) is a technically complex surgical procedure associated with a major risk of hemodynamic instability and metabolic derangement, especially in patients with coexisting renal dysfunction. Some centers have applied intraoperative renal replacement therapy (ioRRT) to support patients with preoperative renal failure and prevent critical complications. Although there is a strong theoretical rationale for this treatment, there remains a paucity of definite data demonstrating its benefits. METHODS: This was a retrospective observational study of all adult patients undergoing intraoperative dialysis in our center from January 2010 till December 2016. RESULTS: The study group consisted of 88 patients with a mean MELD score of 31.4. Six patients underwent simultaneous liver and kidney transplantation. Forty-four (50%) recipients were admitted to the intensive care unit before transplantation, and 19 (21.6%) needed mechanical ventilation. Twenty-eight (31.8%) of the procedures were retransplantations, and 40 (45.4%) patients had been undergoing renal replacement therapy before LT. The mean preoperative serum creatinine was 2.82 ± 1.13 mg/dL. The majority of patients (54.5%) was operated on using the veno-venous bypass technique. The mean arterial blood pH and potassium levels after reperfusion were 7.2 ± 0.12 and 4.04 ± 0.95 mmol/L, respectively. Postreperfusion syndrome (PRS) occurred in 11 (13.9%) patients in whom dialysis started at least 15 minutes before reperfusion. Dialysis circuit clotting occurred in 9.1% of cases. There were no other adverse events of ioRRT. CONCLUSION: Our data suggests that intraoperative dialysis in severely ill patients with a high MELD score is safe and effective. Lower than expected PRS occurrence needs to be confirmed in a study with a control group.

[The role of slow low efficiency dialysis (sled) in renal replacement therapy].

Slow low efficiency dialysis (SLED) is a hybrid technique of renal replacement therapy. It can be performed with a mobile single-pass batch dialysis system (Genius®) or the multifunctional hemodialysis machines, with reduced dialysate flow and the extended duration of the procedure. The present article reviews the recently published data comparing SLED to continuous renal replacement modalities in critically ill patients with acute kidney injury (AKI). The technical aspects as well as the practical advantages of SLED-Genius®are discussed, and our experience of using SLED for intraoperative renal replacement therapy during liver transplantation is shortly presented.

Autologous peripheral blood stem cell transplantation in dialysis-dependent multiple myeloma patients-DAUTOS Study of the Polish Myeloma Study Group.

INTRODUCTION: Dialysis-dependent (DD) multiple myeloma patients (MM) have a poor prognosis and high tumour burden, thus may benefit from autologous peripheral blood stem cell transplantation (auto-PBSCT), however, these patients have an increased risk of toxicity. AIMS: To evaluate the outcomes (toxicity, PFS, OS) of high dose therapy followed by auto-PBSCT during an observational study and after propensity score matching. PATIENTS AND METHODS: Between 2004-2015, 24 DD patients, (aged 38-67 years), ISS 3, treated with auto-PBSCT, requiring dialysis at diagnosis and auto-PBSCT were evaluated, matched and compared to 55 normal renal function MM patients (NRF) with ISS 3 for outcomes of interest. RESULTS: In DD patients compared to NRF patients risk of mucositis (88% vs 55%), infection (79% vs 51%), parenteral nutrition (50% vs 24%), diarrhoea (71% vs 38%), prolonged duration of hospitalisation (medians: 30 vs 21 days), requirement for RBC transfusion (83% vs 36%) were significantly higher, while no significant differences were found in post-transplant response (ORR; 75% vs 87%), 5-year PFS (36% vs 20%) and OS (39% vs 50%). Subgroup analyses based on toxicity supported these results. CONCLUSIONS: Despite the increased risk of toxicity in DD patients these events do not significantly affect both the PFS and OS.

[Current approaches in the treatment of hyperphosphatemia in chronic kidney disease].

Hyperphosphatemia is a common finding in advanced chronic kidney disease (CKD) and is associated with increased morbidity and mortality. Optimal phosphate control in dialysis patients is a real challenge. In the article, the authors discuss the main phosphate-lowering approaches, such as a change of dietary habits with phosphate restriction and pharmacologic treatment. Several old and new currently available oral phosphate binders are reviewed with their advantages and disadvantages.

[Approach to recurrent urinary tract infections in women].

Recurrent urinary tract infections (rUTI), defined as ≥3 UTI/year or ≥2 UTI/half year, are among the most frequent bacterial infections in women and pose a significant clinical challenge to general practitioner. The main risk factors are: sexual activity with different partners, and - in postmenopausal women - urinary incontinence or incomplete voiding. In the article the current treatment and prevention strategies for rUTI are discussed.

[Advances in the management of renal cell carcinoma].

Renal cell carcinoma accounts for about 3-4% of all malignancies and its incidence is steadily rising. The article presents in short the rationale behind the targeted therapies and provides an update on current therapeutic approaches to metastatic renal cell carcinoma. It also summarizes the most recent developments in the immunotherapy such as immune checkpoint inhibitors, anti-cancer vaccines and chimeric antigen receptors on T cells.

[Metaphylaxis of urolithiasis - a neglected field in medicine?]

Urolithiasis is a common condition linked to lifestyle factors and its prevalence is increasing in Europe and United States. Nevertheless, recurrence of urinary stones can be effectively prevented by dietary and life style changes. The review focuses on general dietary recommendations as well as specific medical therapy for kidney stone formers.

[Renal diseases in malignancies]. / Choroby nerek w przebiegu nowotworów zlosliwych.

Malignancies may be associated with a variety of renal complications. These include: acute kidney injury, chronic tubulointerstitial and vascular pathologies as well as paraneoplastic glomerulonephritis. Membranous nephropathy consists a main paraneoplastic glomerulopathy in solid tumors, and minimal change disease is the most common in haematologic malignancies, especially in Hodgkin lymphoma. Epidemiology, pathogenesis, clinical manifestations and management of these conditions are described in the paper.

[Renal diseases in monoclonal gammopathies]. / Choroby nerek w przebiegu gammapatii monoklonalnych.

Monoclonal gammopathies are a group of diseases caused by proliferation of a single clone of plasmocytes - or lymphoplasmacytic cells producing a monoclonal protein. Renal failure occurs in 20-50% of the patients with multiple myeloma, with myeloma cast nephropathy being its major cause. The other mechanisms of kidney injury include hypercalcemia, AL amyloidosis, light chain deposition disease and others. Patients who develop renal impairment have worse survival than those with normal kidney function. This article discusses the pathogenesis, evaluation and therapy of the renal diseases due to monoclonal gammopathies.

[Anti-cancer agents nephrotoxicity]. / Nefrotoksycznosc leków przeciwnowotworowych.

Nephrotoxicity remains an important complication of chemotherapy. There are many different types of kidney injury that can results from anti-cancer drugs, including: acute and chronic tubular injuries, various podocytopathies, crystal nephropathies, thrombotic microangiopathy, and electrolyte wasting syndromes. All these pathologic changes, their diagnosis and treatment, as well as the preventive measures are shortly summarized in the article.

[Nephrological complications in infectious and tropical diseases]. / Powiklania nefrologiczne w chorobach zakaznych i tropikalnych.

Infections cause approximately 1/3 of acute kidney injury (AKI) cases and a substantial number of chronic and end-stage renal failure. Renal disease may also be a side effect of antimicrobial agents. In turn, people suffering from kidney diseases, especially requiring renal replacement therapy are predisposed to severe infections often of atypical clinical course.

[Tumor lysis syndrome]. / Zespól lizy guza.

Tumor lysis syndrome (TLS) is a serious adverse event observed in patients treated for hematologic malignancies and solid tumors, particularly those with a high proliferative rate. An abrupt and massive tumor cell lysis with release their contents into the circulation leads to a rapid development of hyperuricemia, hyperkalemia, hyperphosphatemia, followed by hypocalcemia. If not managed appropriately, these metabolic disturbances may result in acute kidney injury and in life-threatening cardiac complications and even death. This short review summarizes current strategies for diagnosis, risk assessment, prophylaxis, and therapy.

[Acute kidney injury in liver transplantation]. / Ostre uszkodzenie nerek u pacjentów poddawanych przeszczepieniu watroby.

Acute kidney injury (AKI) is a common complication in liver transplant recipients. Affecting ~25% of patients preoperatively, and up to 60% postoperatively significantly worsens the prognosis. Etiology differs depending on the time of its onset, from mostly prerenal before the transplantation, ischemic in the early postoperative period to toxic AKI later on. Liver transplantation is a lenghty and complex procedure with a significant risk of hemodynamic instability, metabolic acidosis and electrolyte disturbances. The article discusses the risk of AKI development in patients undergoing liver transplanation and the indications to renal replacement therapy in the perioperative period.

[Safe and effective diuretic use in chronic kidney disease]. / Jak skutecznie i bezpiecznie leczyc moczopednie chorego z przewlekla choroba nerek?

Recent epidemiological studies show significant prevalence of chronic kidney disease (CKD) in the general population. Diuretics are critical in therapy ofvolume overload and hypertension commonly encountered in these patients. However, they frequently demonstrate relevant diuretic resistance, and from the other hand diuretic overdose may lead to dehydratation and worsening of kidney function. In this paper the main principles of diuretic treatment in CKD are described, including the diuretic agent and its dose selection, as well as adverse effects of the therapy.