Combined liver-kidney transplant beneficial for patients with dual organ disease
Combined liver and kidney transplant appears to benefit patients with diseases in both organs, including those with a condition known as hepatorenal syndrome who have been receiving dialysis for more than two months, according to an article in the August issue of Archives of Surgery, one of the JAMA/Archives journals.
A combined liver and kidney transplant is the procedure of choice for patients with both end-stage liver disease and end-stage renal (kidney) disease, according to background information in the article. However, the decision is more complicated in cases when kidney dysfunction may be temporary. Currently, hepatorenal syndrome--potentially reversible kidney failure combined with cirrhosis or another liver disease--is often treated with liver transplant alone and not a combined procedure. As waiting times for organs increase, more patients with hepatorenal syndrome will likely develop a chronic, irreversible condition that may require a combination transplant.
Richard Ruiz, M.D., and colleagues at the University of California, Los Angeles, reviewed data from 98 patients who underwent 99 combined liver and kidney transplants at one academic medical facility during a 16-year period, from 1988 to 2004. The patients had an average age of 46 years; 76 had primary kidney diseases and 22 had hepatorenal syndrome. For comparison, the researchers also reviewed data from 148 patients with hepatorenal syndrome who underwent a liver transplant alone between 1998 and 2002 and 743 patients who received kidney transplants alone.
Of the 99 combined transplant patients, 31 had died at the end of the analysis. One-, three-, and five-year survival rates were 76, 72 and 70 percent. None of the risk factors analyzed by the researchers, including characteristics of the donor, age of the recipient or previous transplants affected whether or not the patients would die after surgery. In dual transplant patients, 70 percent of the transplanted livers and 76 percent of the transplanted kidneys survived after one year; after three years, 65 percent of the livers and 72 percent of the kidneys; and after five years, 65 percent of the livers and 70 percent of the kidneys. Among those who underwent kidney transplants only, 23 percent of the kidneys were rejected by the recipient's body after one year, compared with 14 percent of those who had liver-kidney transplants.
When compared with hepatorenal syndrome patients who received only liver transplants, those who were undergoing dialysis--use of a machine to perform the blood filtration normally handled by the kidneys--for longer than eight weeks before surgery did better after the combined transplant. "Before this analysis, we recommended combined liver and kidney transplantation when patients receive hemodialysis for longer than one month before transplantation," the authors write. "However, on the basis of current findings, we find that the acuteness of renal failure subsides after two months of hemodialysis and that combined liver and kidney transplantation after this time will not only offer improvement in patient survival but also reduce hospital expenditures for patient care."
"Combined kidney and liver transplantation offers the best option for patients with simultaneous chronic liver and kidney failure when it is performed at a high-volume academic transplant center," they conclude.
(Arch Surg. 2006;141:735-742. Available pre-embargo to the media at http://www.jamamedia.org.)
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