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

Ekser, Burcin MD, PhD*; Mangus, Richard S. MD, MS*; Fridell, Jonathan A. MD*; Kubal, Chandrashekhar A. MD, PhD*; Nagai, Shunji MD, PhD*; Kinsella, Sandra B. MD; Bayt, Demetria R. MPH; Bell, Teresa M. PhD; Powelson, John A. MD*; Goggins, William C. MD*; Tector, A. Joseph MD, PhD*

doi: 10.1097/SLA.0000000000001752
Original Articles

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.

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*Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, IN

Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.

Reprints: Burcin Ekser, MD, PhD, Department of Surgery, Transplant Division, Indiana University School of Medicine, 550 University Blvd, Room 4601, Indianapolis, IN 46202. E-mail:

W.C.G. and A.J.T. shared senior authors.

B.E. is a recipient of a Young Investigator Award from the American Transplant Congress 2015, and a Rising Star Award from the International Liver Transplantation Society 2015. Part of the present work was presented in above-mentioned meetings, and in the 17th Congress of the European Society for Organ Transplantation 2015 in the session of Best Liver Abstracts.

Authors’ contributions: Drs B.E. and R.S.M. had full access to all of the data in the study and take responsibility for the integrity of data and the accuracy of the data analysis; Study concept and design: A.J.T., W.C.G., and J.A.F., B.E.

Acquisition, analysis, or interpretation of data: all authors. Drafting the manuscript: B.E., A.J.T, and J.A.F. Critical revision of the manuscript for important intellectual content: all authors.

Statistical analysis: D.R.B., T.M.B., and B.E. Administrative, technical, or material support: B.E., R.S.M., S.B.K., S.N., C.A.K., and J.A.P. Study supervision: B.E., J.A.F., W.C.G., and A.J.T.

All authors report no conflict of interests.

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