A Novel Approach in Combined Liver and Kidney Transplantation With Long-term Outcomes.

OBJECTIVE: The aim of this study was to compare the outcomes of simultaneous and delayed implantation of kidney grafts in combined liver-kidney transplantation (CLKT). BACKGROUND DATA: Delayed function of the renal graft (DGF), which can result from hypotension and pressor use related to the liver transplantation (LT), may cause worse outcomes in CLKT. METHODS: A total of 130 CLKTs were performed at Indiana University between 2002 and 2015 and studied in an observational cohort study. All kidneys underwent continuous hypothermic pulsatile machine perfusion until transplant: 69 with simultaneous kidney transplantation (KT) (at time of LT, group 1) and 61 with delayed KT (performed at a later time as a second operation, group 2). All patients received continuous veno-venous hemodialysis during the LT. Propensity score match analysis in a 1:1 case-match was performed. RESULTS: Mean kidney cold ischemia time was 10 ± 3 and 50 ± 15 hours, for groups 1 and 2 (P < 0.0001), respectively. The rate of DGF was 7.3% in group 1, but no DGF was seen in group 2 (P = 0.0600). Kidney function was significantly better in group 2, if the implantation of kidneys was delayed >48 hours (P < 0.01). Patient survival was greater in group 2 at 1 year (91%), and 5 year (87%) post-transplantation (P = 0.0019). On multivariate analysis, DGF [hazard ratio (HR), 165.7; 95% confidence interval (CI), 9.4-2926], extended criteria donor kidneys (HR, 15.9; 95% CI 1.8-145.2), and recipient hepatitis C (HR, 5.5; 95% CI 1.7-17.8) were significant independent risk factors for patient survival. CONCLUSIONS: Delayed KT in CLKT (especially if delayed >48 h) is associated with improved kidney function with no DGF post-KT, and improved patient and graft survival.

Mild to moderate pulmonary hypertension in liver transplantation.

BACKGROUND: Patients with pulmonary hypertension (PHTN) are at increased risk for worse outcomes post-liver transplant (LT). This study evaluated LT outcomes and complications for a large number of LT patients with mild to moderate PHTN. MATERIALS AND METHODS: This is a retrospective review of data from 2001 to 2011. All cases of PHTN were diagnosed with catheterization (mean pulmonary artery pressure) and categorized according to standard criteria: low-mild, 25-29 mm Hg; high-mild, 30-34 mm Hg; moderate, 35-44 mm Hg; and severe, ≥45 mm Hg. Our center protocol excludes most patients with known moderate and severe PHTN from LT. Outcomes included early liver function, ventilator time, hospital length of stay, and graft and patient survival. RESULTS: We reviewed the cardiac and pulmonary records for 1263 patients. There were 102 patients with confirmed PHTN (8%): 63 low-mild, 30 high-mild, and 9 moderate. Patients with PHTN were older (P < 0.001). Patients with PHTN were more likely to have prolonged post-transplant ventilator weaning (40% versus 26% >48 h post-transplant; P < 0.01) and a longer length of hospital stay (12 versus 10 d; P = 0.08). The PHTN had a lower 1-y graft survival (79% versus 87%; P = 0.05). There were no statistical differences in early graft function or in long-term patient survival. CONCLUSIONS: These results suggest that PHTN patients require longer post-liver transplant ventilation and length of hospital stay, but have similar early graft function and long-term survival. The risk of PHTN in these patients increases with increasing age.

Pretransplant coronary artery disease associated with worse clinical outcomes in pancreas transplantation.

BACKGROUND: Coronary artery disease (CAD) is common in patients with type I diabetes and may be associated with worse outcomes in patients undergoing pancreas transplantation (PT). This study evaluates PT patients to determine the pre transplant prevalence of CAD and assesses the post-transplant outcomes including complications and survival. METHODS: This study is a retrospective review of PTs from 2003 to 2011. Diagnosis of CAD required cardiac catheterization. Outcomes included: myocardial infarction (MI), stroke, and survival. RESULTS: There were 405 transplants in 389 patients with median follow-up of 56 months. Pre transplant prevalence of CAD was 19% (n = 74). There was no increased risk of perioperative, 90-d or one-yr mortality for patients with CAD. The CAD group did have increased risk of MI (11% vs. 1%, p < 0.001) and stroke (8% vs. 3%, p = 0.02). Controlling for patient and donor age, and history of CAD, the CAD group had decreased patient survival at five yr (82% vs. 90%, p = 0.09, HR 1.77) by Cox regression. CONCLUSIONS: Patients with type I diabetes and CAD have increased risk of MI and stroke post-pancreas transplant, with decreased five-yr survival. Patients without CAD and a negative pre transplant cardiac evaluation carry a low risk of post-transplant MI.