Introduction and Background
A 59-year-old with long-standing diabetes and end-stage liver disease secondary to NASH is being evaluated for a liver transplant. The patient’s baseline serum creatinine was 1.4-1.8 mg/dl but developed an acute increase in creatinine to 2.7 with worsening ascites and a decrease in urine output. After paracentesis, withholding diuretics, and the administration of IV albumin with octreotide, the urine output increased and creatinine decreased to 2.4 mg/dl. The urine sodium was low and both a renal ultrasound and urinalysis were unremarkable for obvious parenchymal renal disease.
Should this patient receive a liver transplant alone (LTA) or simultaneous liver and kidney transplant (SLK).
The discussion focused on three issues:
Determining acceptability for SLK by eGFR
According to the 2016 OPTN Simultaneous Liver Kidney Transplant Guidelines, for acceptance for SLK, a patient requires an eGFR persistently <60ml/min/1.73m2 for 3 months and < 30ml/min/1.73m2 at the time of listing for the Orthotopic Liver Transplant (OLT). We do not have good data on the length of this patient’s CKI, so it is unclear if the patient does or does not fulfill these criterion for listing for an SLK. This is not an unusual scenario and in many ways is why the issue arose in this patient.
Performing an SLK or LTA
The discussants thought that this patient would have a more stable post-operative course if an SLK were performed and thus (assuming primary immediate function of the renal transplant) obviating the need for renal replacement therapy (RRT). This is supported by some literature suggesting a survival advantage to SLK over LTA in patients with renal insufficiency. Even if this patient did not need RRTimmediately post-operatively, the patient’s remaining native kidney function could be further impaired by calcineurin inhibitors that are required to prevent rejection of the OLT and it would just be a matter of time for the patient to require chronic RRT.
The opposite side of this argument is that this patient’s AKI/CKD could simply be related to hepatorenal syndrome pathophysiology which could improve significantly following LTA. This is the basis for the guidelines, many patients will recover significant renal function with a LTA. While it would be easy to error on the safe side for the patient by performing an SLK, giving a kidney to a recipient that doesn’t need it deprives another patient of that organ. In doing this, a precious resource for patients with advanced irreversible CKD and ESRD requiring renal replacement therapy has been squandered. This is no small concern in an environment where waiting lists for cadaver kidneys can average many years.
Efficacy of a kidney biopsy
To further sort this out, some discussants recommended a kidney biopsy be considered (despite the increased risk of this procedure related to bleeding) to help predict the post-OLT renal prognosis and guide the decision to do a SLK as opposed to a LTA.
Deceased donor kidneys should be reserved for this population and not given for simultaneous combined organ transplant unless irreversible CKD/ESRD is strongly suspected.
There was no consensus by the discussants on this most difficult decision. Follow-up revealed patient received LTA a few days following discharge as he was not yet listed for SLK. Fortunately, the new liver functioned immediately. More importantly, the post liver transplant serum creatinine fluctuated between 2.5-2.7 mg/dl for several days followed by progressive decrease and remained stable at 1.1-1.3 mg/dl. In this case, the 2016 SLK eligibility Guidelines prevented the misuse of a valuable resource by preventing an automatic SLK listing.
The SLK eligibility rule is a minimum requirement not a standard of care. This policy was developed on available data in 2016. This rule has a safety net provision that any LTA recipient who developed ESRD within 1 year of transplant will be listed at the top of the local list for a KDPI (Kidney Donor Profile Index) 35-100. Donor kidneys with a lower KDPI statistically function longer.
Please read the full discussion on ASN Communities.