Mitigation of Cytokine Storm by Intraoperative Use of Renal Replacement Therapy During Combined Liver-Kidney Transplantation

Background

Combined liver-kidney transplantation (CLKT) is a widely used multiorgan transplantation with good graft survival rates. Previous studies have shown beneficial effects of renal replacement therapy in critically ill patients. This observation led us to use intraoperative continuous veno-venous hemofiltration (CVVH) during multiorgan transplantations.

Methods

We analyzed (CRP) inflammatory response parameters of tumor necrosis factor (TNF)α, interleukin(IL)-6, procalcitonin (PCT) and C-reactive protein (CRP) at various stages of the combined transplantations.

Results

All patients survived with well-functioning grafts. Mean ± SD follow-up was 32.8 ± 14.2 months. During the whole operation we used intraoperative CVVH starting at the beginning and continuing in the intensive care unit (ICU) afterward (mean ± SD, 11.2 ± 8.4 hours). Intraoperative TNFα, IL-6, CRP, and PCT were measured before surgery, during hepatectomy in the anhepatic phase, before and after liver reperfusion, exactly before kidney reperfusion, after kidney reperfusion, and upon arrival in the ICU. The wash-out of cytokines together with hemodynamic stability gave optimal circumstances for recovery of the transplanted organs.

Conclusions

CVVH-based therapy offered stable intraoperative parameters, prevention of fluid overload, correction of metabolic disturbances, and wash-out of cytokines, which gave optimal circumstances for recovery of transplanted organs.     

Combined Liver-Kidney Transplantation Complicated by Intraoperative Discovery of a Bronchobiliary Fistula

Herein, we report the case of an intraoperative diagnosis of bronchobiliary fistula during combined liver-kidney transplantation because of polycystic disease. The diagnosis necessitated changes in surgical and anesthesiologic management and in the overall medical decision-making process. Emergent isolation of the affected lung was instituted to mitigate a large air leak and ensure adequate respiratory exchange, and to enable surgical repair. The kidney transplantation procedure was delayed for a few hours, enabling hemodynamic and respiratory stabilization in the intensive care unit before conditions were deemed adequate to proceed. The posttransplantation course was complicated but eventually successful, and the patient recovered both liver and kidney function. At a later evaluation, we realized that diagnosis of bronchobiliary fistula could have been made preoperatively had the chest radiograph been interpreted correctly and had the clinicians involved had a higher degree of suspicion for this complication of polycystic liver disease.     

Use of Intravenous Hydroxocobalamin for Vasoplegic Syndrome in Simultaneous Liver-Kidney Transplant: A Case Report

Vasoplegic syndrome can occur after reperfusion in liver transplantation. Generally, vasopressor infusions along with volume resuscitation are used to combat this process. There are case reports of the use of hydroxocobalamin to improve vasoplegia in liver transplant and cardiac surgery. In this case report, we describe a patient who received hydroxocobalamin for a simultaneous liver-kidney transplant. Use of this medication facilitated a prompt decrease of very high-dose vasopressor infusions and allowed completion of the kidney transplantation portion of this case. To our knowledge, use in combined liver-kidney transplant has not been described. In light of the dearth of medications to improve vasoplegia outside of vasopressor infusions, the use of hydroxocobalamin as a therapeutic intervention may gain importance.     

Difference in Survival in Early Kidney after Liver Transplantation Compared with Simultaneous Liver-Kidney Transplantation: Evaluating the Potential of the “Safety Net”

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Direct Correlation of Soluble HLA and HLA-Containing Exosomes and Inverse Correlation of Tolerance Marker-Containing Exosomes With Antibody-Mediated Rejection After Simultaneous Liver-Kidney Transplantation: A Case Study

There is a lower incidence of antibody-mediated rejection (AMR) after simultaneous liver-kidney transplantation (SLKT) than after kidney-only transplantation. It has been suggested that soluble human leukocyte antigen (sHLA) produced by the liver protects the kidney from AMR. However, this hypothesis has not been tested after SLKT. We present a case of SLKT with 2 donor-specific antibodies (DSAs) (DR53, 12,364 mean fluorescence intensity [MFI]; DQ7, 1253 MFI) that displayed a decrease by day 7 (DR53, 2747 MFI; DQ7, 107 MFI). On day 351, the patient was diagnosed with kidney AMR associated with high levels of DSA (DR53, 18,542 MFI; DQ7, 22,007 MFI) that persisted until day 531. High levels of sHLA-DR/DQ and HLA-DR/DQ-containing exosomes were also detected on day 398. Consequently, the patient underwent treatment with plasmapheresis, intravenous immunoglobulin, prednisone, and rituximab. On day 752, biopsy results were negative for AMR. Moderate levels of DSA (DR53, 9798 MFI; DQ7, 1271 MFI), and baseline levels of sHLA-DR/DQ and HLA-DR/DQ-containing exosomes were observed. Increases in CD4⁺CD25⁺FOXP3⁺ regulatory T cell marker–containing exosomes (CD73, programmed death-ligand 1) were observed on day 752 compared to day 398. These data show a direct correlation between sHLA and HLA-containing exosomes and an inverse correlation between tolerance marker–containing exosomes and kidney AMR after SLKT.     

Influence of Long-term Dialysis on the Outcome of Kidney Transplantation: A Single-Center Study

Aim

We investigated clinical outcomes of patients in Japan with a history of long-term dialysis treatment.

Combined Liver-Kidney Transplantation in Children: Single-Center Experiences and Long-Term Results

Combined liver-kidney transplantation (CLKT) is a rare procedure in pediatric patients in which liver and kidney from 1 donor are transplanted to a recipient during a single operation. The aim of our study was to analyze indications and results of CLKT in children.

Combined Liver-Kidney Transplantation: Survey of a Single Center in Spain

BackgroundRenal dysfunction is a common complication of advanced liver failure and liver transplantation. Since the introduction of the MELD criteria the proportion of patients with advanced chronic kidney disease and need for liver transplantation has increased. One alternative is the combined liver-kidney transplant (CLKT). The aim of this study was to evaluate the outcome of this type of transplant in our center.MethodsWe retrospectively analyzed all combined simultaneous or sequential transplants from 1989 to 2012. We studied demographic and clinical variables. Survival analysis was performed by Kaplan-Meier method.ResultsIn the study period, 1,265 kidney and 1,050 liver transplantations were performed; 34 were CLKT (to 29 adults and 5 children); 13 of these were simultaneous and 12 sequential liver-kidney. We also carried out 4 triple liver-pancreas-kidney transplantations, 3 simultaneous and 1 sequential. The mean age was 44.1 ± 15 years, and 27 were male (93.1%); 9 (37.5%) were diabetic. The main causes of liver disease were viral (n = 11 [41.3%; hepatitis virus B, C, or both] and alcoholism (9 [31%]). The renal disease etiology was unknown in 16 (55.1%), IgA nephropathy in 2 (6.8%), membranoproliferative glomerulonephritis in 2 (6.8%), and calcineurin inhibitor toxicity in 4 (13.6%). Transjugular renal biopsy was performed in 6 sequential transplants. Survival of patients who received a CLKT was excellent: 91%, 51%, and 40%, at 1, 5, and 10 years, respectively. No significant difference was found between sequential and simultaneous transplants (log rank 0.5).ConclusionsOur results of CLKT show results similar or superior to those of other series and are an alternative to consider in candidates for liver transplantation with chronic kidney disease. Transjugular biopsy is an alternative to study the etiology of renal disease in patients with hepatic dysfunction before or after liver transplantation.     

Renal Allograft Outcome in Recipients of Positive-Crossmatch Combined Liver-Kidney Transplantation

Background

Successful kidney transplantation despite positive crossmatch (+CXM) before transplantation is well recognized in combined liver-kidney transplant (CLKT) recipients. This is probably due to immunologic protection of the renal allograft (RA) conferred by the liver allograft. However, occurrences of antibody-mediated rejection and poor long-term RA outcome is also documented with +CXM CLKT recipients, suggesting that such immunologic protection may not be universal.

Methods

A total of 1,401 CLKT recipients with known status of pre-transplantation CXM were identified from the United Network for Organ Sharing registry from January 1, 1986, to December 31, 2006. Univariate analysis for significant differences in clinical variables and Kaplan-Meier estimate for patient and graft survivals were performed. The results were compared between positive and negative CXM groups.

Results

Pre-transplantation +CXM was seen in 17.3% (242/1401) of CLKT recipients studied. The demographic and clinical characteristics were similar between the groups, except for higher panel reactive antibody level and CXM positivity in female recipients. Outcome analysis showed higher RA rejection (19.3% vs 10.8%; P = .026) and increased hospital length of stay (37.3 ± 46.0 vs 28.8 ± 33.2 days; P = .028) in the +CXM group. RA survivals at 1, 3, and 5 years were 8%, 7%, and 6% lower in the +CXM group. The patient and liver allograft survivals were not different between the groups.

Conclusions

In CLKT recipients with pre-transplantation +CXM, the immunologic protection of RA conferred by the liver allograft is less robust than previously perceived and may lead to higher rejection rate and poor RA outcome. This can be mitigated with routine pre-transplantation CXM.     

Intraoperative Support for Primary Bilateral Lung Transplantation: A Propensity-Matched Analysis

BackgroundSingle-center studies support benefits of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a method of intraoperative support. Propensity-matched data from a large cohort, however, are currently lacking. Therefore, our goal was to compare outcomes of intraoperative VA-ECMO and cardiopulmonary bypass (CPB) during bilateral lung transplantation (LTx) with a propensity analysis.MethodsWe performed a retrospective analysis of 795 consecutive primary adult LTx patients (June 1, 2011-December 26, 2020) using no intraoperative support (n = 210), VA-ECMO (n = 150), or CPB (n = 197). Exclusion criteria included LTx on venovenous-ECMO, single/redo LTx, ex vivo lung perfusion, and concomitant solid-organ transplantation or cardiac procedure. Propensity analysis was performed comparing patients who underwent intraoperative CPB or VA-ECMO.ResultsThe propensity CPB group required more blood products at 72 hours (P = .02) and longer intensive care unit length of stay (P < .001) and ventilator dependence days (P < .001). There were no differences in cerebrovascular accident (P = 1), reintubation (P = .4), dialysis (P = .068), in-hospital mortality (P = .33), and 1-year (P = .67) and 3-year (P = .32) survival. The CPB group had a higher incidence of grade 3 primary graft dysfunction at 72 hours (P < .001). Neither support strategy was a predictor of 1- and 3-year mortality in our multivariable model (VA-ECMO, P = .72 and P = .57; CPB, P = .45 and P = .91, respectively).ConclusionsIntraoperative VA-ECMO during lung transplantation was associated with fewer postoperative blood transfusions, shorter length of mechanical ventilation, and lower incidence of a grade 3 primary graft dysfunction at 72 hours. Although there were some differences in the postoperative course between the VA-ECMO and CPB groups, support type was not associated with differences in survival.     

胰肾联合移植的指征和现状

近 40年来 ,胰腺移植在基础和临床研究方面都获得了令人振奋的长足进步。据国际胰腺移植登记中心 (IPTR)记录 ,全球已实施了 1890 0余例胰腺移植 (截至 2 0 0 2年 10月 ) ,其中绝大多数在美国 (近 14 0 0 0例 ) ,约 90 %为胰肾联合移植(SPK)。迄今为止 ,SPK被公认是治疗糖尿病合并肾功能衰竭的最有效的方法。据报道 ,胰腺移植受体 1年生存率超过95 % ,3年生存率接近 90 % ;移植胰腺有功能 (患者不依赖胰岛素 )者的 1年和 3年生存率分别为 83 %和 77% [1,2 ] 。1　胰肾联合移植的历史演进历史上 ,首例胰肾联合移植于 1966年 12月 16日在…     

Demography of Dialysis and Transplantation in Europe, 1984: Report from the European Dialysis and Transplant Association Registry

The demography of renal replacement therapy up until the closeof 1984 in Europe is presented, based on return of individualpatient questionnaires to the EDTA Registry. These were completedby 84.7% of known centres in 33 countries. Of 187 267 individuallyregistered patients, 102 276 were known to be alive on definedforms of renal replacement therapy on 31 December 1984. Thestock of patients alive on treatment by dialysis and transplantationin Europe continued to grow and exceeded 200 per million populationin 14 European countries at the end of 1984. During the sameyear, 21 198 new patients were accepted for treatment in Europe,and crude acceptance rates for new patients exceeded 60 permillion population in four countries. Acceptance rates for elderlypatients continued to increase and age specific acceptance ratesfor males aged 65 and over exceeded 100 per million populationin 12 countries. A total of 6802 renal transplants were reportedduring 1984. Regrafting accounted for a higher proportion oftransplants in Nordic countries and in the United Kingdom, comparedwith other nations. During 1984 the total number of transplantsreported to the Registry passed 50 000. The distribution ofprimary renal disease amongst adult patients commencing treatmentin 1984 is presented. Amongst elderly patients commencing treatment,a strikingly high proportion have chronic renal failure of uncertainaetiology. Finally, causes of death have been analysed amongstadult patients dying during 1984, showing myocardial ischaemiaand infarction to be the leading cause of mortality.     

Use of Intraoperative Duplex Ultrasound and Resistance Index Reduces Complications in Living Renal Donor Transplantation

Background

The treatment of choice in end-stage renal disease is transplantation. Hemodynamic disturbances can evoke graft loss, while early ultrasound identification of vascular problems improves outcome. The aim of this study was to identify differences in postoperative complications with and without systematic intraoperative Doppler ultrasound use.

Infections After Simultaneous Pancreas and Kidney Transplantation: A Single-Center Experience

Simultaneous pancreas-kidney transplantation (SPKT) is now an accepted therapy for patients with insulin-dependent diabetes mellitus. However, SPKT has an high rate of morbidity and mortality, mainly for infection. From October 1986 to June 2008, in our center 54 patients (18 female; 36 male) affected by diabetes and end-stage renal disease underwent SPKT. The mean duration of diabetes mellitus was 25 ± 4 years. Only 4 patients had not been treated by dialysis before SPKT. Three operative techniques were used: duct injection (n = 5), bladder diversion (n = 14), and enteric diversion (n = 39). The kidneys were always placed into the left retroperitoneal space. The pancreas was placed extraperitoneally in 5 patients. Thirty-four recipients are alive, including 30 with function of both grafts. Six patients died during the first year after transplantation. Infectious complications were the main cause of death in 3 subjects whereas 98 infections were diagnosed in 51 patients. All patients were treated with immunosuppressive agents: steroids associated with calcineurin inhibitors and mycophenolic acid, or azathioprine. Antibody induction was used in 41 patients with anti-interleukin-2 monoclonal antibody or antithymocyte globulin. We detected 41 episodes of cytomegalovirus infection: systemic (n = 38), bladder (n = 2), and duodenal (n = 1). The 51 bacterial infections were systemic: (n = 10); urinary tract: (n = 22); pulmonary (n = 11); wound (n = 5); intestinal (n = 3). The 5 fungal infections were gastrointestinal tract (n = 3); and arteritis (n = 2). Some patients experienced more than 1 type of infection. The predominant etiology of the systemic infections was bacterial. In conclusion, infectious complications were the main causes of morbidity after SPKT. An early diagnosis of infection, particularly fungal complications, is essential. We recommend administration of broad-spectrum prophylactic antibiotics, antifungals, and antiviral agents.