John A. Bertolatus, MD

Disclosures

December 11, 2001

Question

I would like to know your position on the indication of combined liver-kidney transplantation for patients in end-stage renal disease with Child's class A cirrhosis and no history of decompensation.

Ajacio Brandão, MD

Response from John A. Bertolatus, MD

Patients who have the combination of chronic liver disease and chronic kidney disease, leading to end-stage failure of both organs, are encountered quite frequently. There are many reasons for the common occurrence of liver disease and kidney disease, including the relatively high frequency of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in the end-stage renal disease (ESRD) population, the development of renal disease due to glomerulopathies in patients with HBV or HCV infection, and the incidence of chronic renal failure in patients who have previously undergone liver transplantation (probably mostly due to calcineurin inhibitor nephrotoxicity). There are also a few unique situations that lead to consideration for combined liver-kidney transplantation in individuals with noncirrhotic hepatic problems, such as primary hyperoxaluria Type I and polycystic liver disease.

Most of the literature concerning combined liver-kidney transplantation (CLKT) focuses on patients who present with advanced decompensated liver disease who coincidentally have renal impairment.[1] Most of these individuals presumably have Child's class B or C cirrhosis, and therefore qualify for listing for liver transplantation in the United States under current United Network for Organ Sharing (UNOS) criteria. From 1988 through 1999, there were 762 CLKTs reported to UNOS, representing approximately 2% to 3% of all liver transplants.[1] The most common indications were polycystic kidney-liver disease and primary hyperoxaluria. However, most reports do not give details of the status of liver disease in these patients undergoing CLKT.

It is clear that the presence of renal impairment at the time of liver transplantation is associated with poorer outcomes. Some authors have asserted that the outcome of patients with combined liver-kidney failure can be improved by performing CLKT. However, other centers have presented results demonstrating that in patients with renal impairment at the time of transplantation, equivalent outcomes may be obtained by liver transplantation alone.[2] The etiology of the renal impairment is probably critical in deciding the best approach for the patient with combined hepatic and renal failure. Many individuals with advanced liver disease will develop hepatorenal syndrome (HRS), a condition in which the kidneys are functionally impaired but structurally intact. The current consensus seems to be that renal failure due to HRS will recover eventually in most cases, so that use of cadaveric donor kidneys in these cases is not justified. Sequential renal transplantation can then be offered if renal function does not eventually recover.

The patient with end-stage renal failure who has compensated cirrhosis presents a difficult dilemma, especially when one reviews the current guidelines for wait-listing of potential transplant recipients[3,4] and current UNOS allocation policy.[5] The current clinical practice guidelines of the American Society of Transplantation suggest that patients with ESRD and cirrhosis might best be counseled to remain on dialysis, although it is acknowledged that there are few data upon which to base this recommendation.[4] The principal concern appears to be the significant risk of hepatic decompensation with anesthesia and surgery. The possibility of CLKT is mentioned, but no further guidelines concerning that option are presented. Addressing the problem from the standpoint of the liver disease, it seems clear that individuals with compensated (eg, Child's class A) cirrhosis are generally not deemed appropriate for listing for transplantation because of the variable long-term history.[3]

The UNOS policies present another possible difficulty.[5] It is clear that individuals who are listed for liver transplantation (presumably for the standard indications) may at the time of transplantation receive a kidney from the same donor from whom the liver is procured. The rationale is that these individuals require life-saving transplantation (liver), and can receive a kidney at the same time without depriving another person of a life-saving organ (because of the availability of dialysis for treatment of ESRD). However, a patient listed only on the kidney waiting list is not entitled to the same treatment because of the concern that such a policy might divert a life-saving cadaveric liver to someone whose need for a liver is not as great as that of others awaiting liver transplantation.

Despite the above difficulties, it seems clear to me that an individual with ESRD and cirrhosis deserves careful consideration for CLKT, even if the cirrhosis is compensated. Recently, data have been presented that show a convincing survival advantage with treatment of ESRD by kidney transplantation, rather than dialysis,[6] leading to the consideration that kidney transplantation may also be at least relatively "life-saving," though perhaps not quite in the same sense as liver transplantation. While the survival advantage with kidney transplantation may not be observed in the small subset of patients with concomitant hepatic cirrhosis, there is still the issue of better quality of life with transplantation. Because the significantly elevated risk of kidney transplant surgery in a cirrhotic patient can most likely be reduced by performing CLKT, it makes sense to take that approach. This recommendation would be predicated on documentation that the renal failure was advanced and permanent, and that presence of cirrhosis was also well documented.

In addition, there are 2 special circumstances, mentioned above, which more clearly warrant CLKT. In primary hyperoxaluria type I, kidney transplantation alone is generally associated with a disappointing outcome due to recurrent renal oxalosis, while performance of the liver transplant corrects the underlying metabolic disorder and protects the new kidney and other organs from oxalate deposition. In polycystic kidney disease, occasional patients may have such extensive cystic liver disease that they experience pain, bleeding, or infection of such severity that CLKT is warranted.

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