Results of simultaneous and sequential pediatric liver and kidney transplantation

Background. The indications for simultaneous and sequential pediatric liver (LTx) and kidney (KTx) transplantation have not been well defined. We here in report the results of our experience with these procedures in children w ith end-stage liver disease and/or subsequent end-stage renal disease. Patients and Methods. Between 1984 and 1995, 12 LTx recipients received 15 kidney allografts. Eight simultaneous and seven sequential LTx/KTx were per formed. There were six males and six females, with a mean age of 10.9 years (1.5-23.7). One of the eight simultaneous LTx/KTx was part of a multivisce ral allograft. Five KTx were performed at varied intervals after successful LTx, one KTx was performed after a previous simultaneous LTx/KTx, and one KTx was performed after previous sequential LTx/KTx. Immunosuppression was with tacrolimus or cyclosporine and steroids. Indications for LTx were oxal osis (four), congenital hepatic fibrosis (two), cystinosis (one), polycysti c liver disease (one), A-1-A deficiency (one), Total Parenteral Nutrition ( TPN)-related (one), cryptogenic cirrhosis (one), and hepatoblastoma (one). Indications for KTx were oxalosis (four), drug-induced (four), polycystic k idney disease (three), cystinosis (one), and glomerulonephritis (1). Results. With a mean follow-up of 58 months (0.9-130), the overall patient survival rate was 58% (7/12). One-year and 5-year actuarial patient surviva l rates were 66% and 58%, respectively. Patient survival rates at 1 year af ter KTx according to United Network of Organ Sharing (liver) status were 10 0% for status 3, 50% for status 2, and 0% for status 1. The overall renal a llograft survival rate was 47%. Actuarial renal allograft survival rates we re 53% at 1 and 5 years. The overall hepatic allograft survival rate was eq uivalent to the overall patient survival rate (58%). Six of seven surviving patients have normal renal allograft function, and one patient has moderat e chronic allograft nephropathy. All surviving patients have normal hepatic allograft function. Six (86%) of seven sequentially transplanted kidneys d eveloped acute cellular rejection compared with only two (25%) of eight sim ultaneously transplanted kidneys (P<0.04). Conclusions. Simultaneously transplanted kidneys were less likely to develo p rejection than sequentially transplanted kidneys in this series. This did not have any bearing on patient or graft survival rates. Mortality correla ted directly with the severity of United Network of Organ Sharing status at the time of kidney transplantation. Candidates for simultaneous or sequent ial LTx/KTx should be prioritized based on medical stability to optimize di stribution of scarce renal allografts.