Pulsatile Perfusion and Delayed Renal Transplantation (Tx) for Combined Liver-Kidney Tx.

Abstract

Background: Patients requiring combined liver and kidney transplantation (LKTx) are at risk for worse outcomes due to severity of illness and complexity of the procedure. Delayed function of the renal graft can result from hypotension and pressor use related to the LTx procedure. Delayed Tx of the kidney graft may allow post-LTx stabilization of hemodynamics and coagulopathy. Methods: 95 LKTx were performed between 2002-2012 at our center. All kidneys underwent continuous hypothermic pulsatile perfusion until Tx; 70 with simultaneous (at time of LTx, Gp1) and 25 with delayed Tx (Gp2, performed at a later time as a second operation). The median MELD score was 26. In each case, the kidney was transplanted through a separate Gibson incision in the left pelvis. All patients received continuous veno-venous hemodialysis during the LTx which was continued until KTx. Results: Recipient, donor and transplant characteristics were comparable in both groups. Mean liver cold ischemia time (CIT) was less than 7 hours in both groups, while kidney CIT was 10±3 (range 5-19) and 37±9 (range 20-53) hours, for Gp1 and Gp2 (p<0.001), respectively. The two study groups did not differ significantly for dialysis in the first 7 days, nor for urine output in the first 24 hours. GFR was higher for Gp2 at 6- and 12-months (73 vs 67 at 6 months and 73 vs 64 at 12 months) (p=ns). In Gp1, mean FFP and platelet transfusions were higher (p<0.01). In Gp2, at the time of KTx, 9 patients (36%) didn't require any blood product transfusion, and 15 (60%) required significantly less transfusion. In delayed approach (Gp2), of 11 patients who were on pressors post-LTx, 3 were off (27%) and 7 had decreased need for pressors (64%) at the time of KTx. Sub-group analyses in Gp2 (kidney CIT <36h [Gp2a, n=11], and >36h [Gp2b, n=14]) showed similar GFR, graft (kidney and liver) and patient survival rates at 1-year. Graft and patient survivals in Gp1 and Gp2 at 90-days and 1-year were equivalent. 3-year Cox regression survival for the kidney graft was equivalent (82%). Conclusion: In LKTx patients, KTx can be safely delayed up to 2 days post-LTx with outcomes comparable to simultaneous Tx. Delayed Tx of the kidney post-LTx allows time for stabilization of the patient and decrease in pressor needs (up to 90%), and creates flexibility for the management of patients and personnel at a high-volume transplant center.