Graft quality matters: Survival after simultaneous liver-kidney transplant according to KDPI.

BACKGROUND: Poor renal function is associated with higher mortality after liver transplantation. Our aim was to understand the impact of kidney graft quality according to the kidney donor profile index (KDPI) score on survival after simultaneous liver-kidney (SLK) transplantation. METHODS: Using United Network of Organ Sharing data from 2002 to 2013 for adult deceased donor SLK recipients, we compared survival and renal graft outcomes according to KDPI. RESULTS: Of 4207 SLK transplants, 6% were from KDPI >85% donors. KDPI >85% recipients had significantly increased mortality (HR=1.83, 95%CI=1.44-2.31) after adjusting for recipient factors. Additionally, dialysis in the first week (HR=1.4, 95%CI=1.2-1.7) and death-censored kidney graft failure at 1 year (HR=5.7, 95%CI=4.6-7.0) were associated with increased mortality after adjusting for recipient factors and liver donor risk index score. CONCLUSIONS: KDPI >85% recipients had worse patient and graft survival after SLK. Poor renal allograft outcomes including dialysis in the first week and death-censored kidney graft failure at 1 year, which occurred more frequently with KDPI >85% grafts, were associated with significantly reduced patient survival. Questions remain about the survival impact of liver vs kidney graft quality given the close relationship between donor factors contributing to both, but KDPI can still be valuable as a metric readily available at the time of organ offers for SLK candidates.

Surgical treatment of an extrarenal pseudoaneurysm after kidney transplantation.

A 69-year-old man who underwent a kidney transplantation developed a large pseudoaneurysm at the anastomosis between the right external iliac artery and renal transplant artery. After an unsuccessful attempt using percutaneous thrombin injection, the patient underwent open exploratory laparotomy and surgical ligation of the pseudoaneurysm with preservation of renal graft function.

Limited efficacy and unacceptable toxicity of cyclophosphamide for the induction of mixed chimerism and renal allograft tolerance in cynomolgus monkeys.

To induce mixed chimerism and renal allograft tolerance in cynomolgus monkeys, cyclophosphamide (CP) and total body irradiation (TBI) were compared as part of a nonmyeloablative conditioning regimen. CP induced dose-dependent neutropenia and lymphopenia, but hematopoietic recovery was more rapid than that observed in the TBI group. Absolute B cell counts after CP were significantly higher (P<0.01) than those in the TBI group. With CP, a total dose of 200 mg/kg with CD154 blockade regularly induced multilineage chimerism. Nevertheless, the recipients failed to achieve long-term survival because of rejection (3 of 5), posttransplantation B cell lymphoma (1 of 5), and toxicities of CP (1 of 5). As previously reported, 3 Gy of TBI with either splenectomy or CD154 blockade induced mixed chimerism and renal allograft tolerance, with significantly less morbidity and mortality than that produced by CP. Thus, TBI is more effective and less toxic than CP as part of a nonmyeloablative regimen for the induction of mixed chimerism and renal allograft tolerance in cynomolgus monkeys.

Liver transplantation at the University of Texas Health Science Center/University Hospital in San Antonio.

Liver transplantation is the only potentially curative treatment for patients with end-stage liver disease. An extensive medical and psychosocial evaluation is performed in an attempt to determine which patients are likely to have acceptable outcomes with the procedure. The limited number of donor livers relative to patients that need a liver transplant, and the occurrence of significant deaths in the waiting group, has motivated many transplant programs to agree to put living donors at risk to help solve this problem. Other complex operative techniques such as splitting livers for use in 2 patients have improved the organ availability for pediatric and adult patients. Growth of a liver transplant program from a small program to a large program necessitates institutional, hospital capacity and infrastructure support at many levels to be successful. This requires a strong partnership between the physicians and the hospital system. 1. The University of Texas Health Science Center/University Hospital in San Antonio has performed 610 liver transplants over ten years. Overall one- and 5-year patient survival rates were 88% and 75%, respectively, despite transplanting a relatively advanced population of patients based on MELD scoring. 2. The most frequent indication for liver transplantation was hepatitis C (52% of patients) and the one-, 5-, and 10-year survival rates for transplantation for hepatitis C was equivalent to survival rates after liver transplantation for other indications, despite significant recurrent hepatitis C liver injury. 3. Technical refinements have decreased operative times and immunosuppressive advances have decreased the side effects while maintaining excellent outcomes. Veno-venous bypass and the placement of biliary T-tubes are not currently used. Standard immunosuppression is lower dose Prograf, Cellcept and steroids with Cellcept being weaned off at 3 months and steroids weaned off by one year. 4. Strategies to increase the donor pool including the use of older donors, the use of steatotic livers, the use of split livers and living liver donors for children and adults are all being used successfully at UTHSCSA.