Simultaneous liver-kidney transplantation or liver transplantation alone for patients in need of liver transplantation with renal dysfunction

PURPOSE OF REVIEW: There have been no well defined guidelines to determine whether a kidney transplant should be offered to liver transplant candidates who have chronic kidney disease (CKD) or prolonged acute kidney injury while awaiting a liver transplant. This article provides a review of current literature on risk factors for CKD progression after liver transplantation alone (LTA) in patients with pretransplant renal dysfunction and the utility of cystatin C (Cyst C) to assess renal function in cirrhotic patients. Studies evaluating risk factors for transplant futility are also discussed. Based on available literature and existing consensus guidelines, a proposed algorithm for simultaneous liver-kidney transplantation (SLKT) or LTA is formulated.

RECENT FINDINGS: In LTA recipients with pretransplant renal dysfunction, diabetes mellitus and type 2 hepatorenal syndrome are associated with CKD progression posttransplant. Coexisting diabetes and stages 3-4 CKD increase end-stage renal disease risk. Cyst C may be a better marker of renal function in cirrhotics. In LTA recipients, very high MELD scores and the concomitant presence of multiple comorbidities increase liver transplant futility risk. Similar studies in SLKT recipients are lacking.

SUMMARY: Pretransplant diabetes status should be incorporated into future guidelines for SLKT, whereas simultaneous kidney transplantation should be deferred in highest acuity SLKT candidates with high kidney transplant futility risk. Cyst C-based equations may allow clinicians to better select the most appropriate candidates for SLKT or LTA. Further studies are needed.