Outcomes after combined liver-kidney transplant vs. kidney transplant followed by liver transplant

• Published in: Clinical transplantation Vol. 29; no. 1; pp. 60 - 66
• Main Authors: Chan, Edie Y., Bhattacharya, Renuka, Eswaran, Sheila, Hertl, Martin, Shah, Nikunj, Fayek, Sameh, Cohen, Eric B., Hollinger, Edward F., Olaitan, Oyedolamu, Jensik, Stephen C., Perkins, James D.
• Format: Journal Article
• Language: English
• Published: Denmark Blackwell Publishing Ltd 01.01.2015
• Subjects: Adult; Aged; cirrhosis; combined liver-kidney transplant; Databases, Factual; Female; Graft Survival; Humans; Kidney Failure, Chronic - complications; Kidney Failure, Chronic - mortality; Kidney Failure, Chronic - surgery; kidney transplant; Kidney Transplantation - mortality; Liver Cirrhosis - complications; Liver Cirrhosis - mortality; Liver Cirrhosis - surgery; liver transplant; Liver Transplantation - mortality; Male; Middle Aged; outcomes; Survival Analysis; Time Factors; Treatment Outcome; Waiting Lists; combined liver-kidney transplant; kidney transplant; outcomes; liver transplant; cirrhosis
• ISSN: 0902-0063; 1399-0012
• DOI: 10.1111/ctr.12484

Introduction The decision for isolated kidney transplant (KT) vs. combined liver–kidney transplant (CLKT) in patients with end‐stage renal disease (ESRD) with compensated cirrhosis remains controversial. We sought to determine outcomes of patients requiring listing for a liver transplant (LT) following either a cadaveric or living donor KT and compare these outcomes to similar patients receiving a CLKT. Methods Our dataset included the United Network for Organ Sharing (UNOS)/Standard Transplant and Analysis and Research (STAR) kidney files from 1987 to 2012 after being joined with the liver files from 2002 to 2012. Outcomes of patients who received a CLKT with an international normalized ratio (INR) ≤1 and total bilirubin ≤1 were compared to patients who received a primary KT and subsequently required listing for LT between zero and five yr or after five yr. Results For the three groups, 244 patients had a CLKT, 216 were wait‐listed for LT between zero and five yr after KT (0–5 WL), and 320 were wait‐listed five yr after KT (+5 WL). From the time of KT, the 0–5 WL group had significantly worse survival than the CLKT group and the +5 WL group. The +5 WL had the best survival of all groups. For the 0–5 WL group, 45% underwent LT and 40% died while waiting compared to the +5 WL group with 53% having LT and 26% died while waiting. At the time of LT, the 0–5 WL group had a higher model for end‐stage liver disease (MELD) score, higher incidence of being in the ICU at the time of transplant, and higher incidence of requiring life support. From the time of LT, the CLKT trended toward better survival (p = 0.0549) than both the 0–5 WL and +5 WL groups, which had equivalent survival. Conclusion The 0–5 WL group is a higher risk group with poorer survival due to a higher incidence of dying on the waitlist. Better identification of patients with a high risk for hepatic decompensation following KT and agreement for regional exception for LT in the event of decompensation may improve utilization of organs and better survival for those patients.