Combined liver-kidney transplantation in patients with cirrhosis and renalfailure: Effect of a positive cross-match and benefits of combined transplantation

Patients with renal failure after liver transplantation have a particularly poor prognosis, Therefore, in the setting of end-stage renal disease requi ring dialysis or severe renal insufficiency that will not improve after liv er replacement, combined liver-kidney transplantation (LKT) is the preferre d approach. We have adopted a policy of LKT in patients with end-stage live r disease and renal insufficiency undergoing dialysis or with a creatinine clearance less than 35 mL/min and evidence of chronic renal dysfunction, Si nce 1991, we have performed 208 orthotopic liver transplantations. Fourteen patients (8%) have undergone combined LKT, including 6 patients undergoing hemodialysis, Cytotoxic cross-matches (modified Amos technique and antihum an globulin method) were performed on 13 of 14 patients and were positive i n 3 patients. Two patients died less than 4 months after LKT and 12 patient s are alive and well. Graft survival censored for patient death was 100% fo r liver allografts and 93% for renal allografts, with a mean follow-up of 3 9 +/- 24 months. The most recent serum creatinine level in the patients wit h the 11 functioning grafts was 1.1 +/- 0.6 mg/dL. Biopsy-proven acute reje ction occurred in 50% of simultaneous liver allografts, By contrast, only a single episode (6%) of renal allograft dysfunction was attributable to acu te rejection. All rejection episodes occurred in the first 90 days after tr ansplantation and were steroid sensitive. Three of 14 combined procedures w ere performed in the setting of a positive cytotoxic cross-match. in 2 rece nt patients, the results were confirmed by positive cross-matches to the do nor's T and B cells by flow cytometry. Flow cytometric cross-matches revert ed to negative 1 hour after liver transplantation and several hours before the administration of antithymocyte globulin. The cross-matches remained ne gative on postoperative days 1 and 7. Presently all 3 patients with a posit ive cross-match enjoy normal hepatic and renal function at 631, 706, and 22 75 days follow-up. Renal scans were performed in 4 LKT recipients not previ ously undergoing hemodialysis and indicated varying and unpredictable degre es of function in the native and transplanted kidneys. In conclusion, combi ned LKT can be performed safely and is associated with a tow rate of acute rejection, even in the setting of a positive cross-match. Predicting which patients with renal insufficiency will benefit from LKT remains challenging ; however, these results suggest that LKT should be encouraged in patients with evidence of irreversible renal insufficiency who require liver transpl antation. Copyright (C) 1998 by the American Association for the Study of L iver Diseases.