Die kombinierte und sequentielle Leber-Nieren-Transplantation

Zusammenfassung

Die kombinierte Leber-Nieren-Transplantation (CLKT) und die Nierentransplantation nach Lebertransplantation (KALT) haben sich inzwischen zu etablierten Verfahren bei Patienten mit terminaler Leber- und Niereninsuffizienz entwickelt, mit einer stetig steigenden Anzahl an Transplantationen in den letzten Jahren. Die häufigsten Indikationen zur CLKT bei Erwachsenen sind die familiäre Zystennierenerkrankung mit schwerer Leberbeteiligung und die Leberzirrhose unterschiedlicher Genese mit begleitender terminaler oder präterminaler Niereninsuffizienz infolge chronischer Glomerulonephritis oder diabetischer Nephropathie. Hauptindikation zur CLKT bei Kindern ist die primäre Hyperoxalurie Typ I. Die KALT wird derzeit noch am häufigsten aufgrund einer Kalzineurininhibitor-induzierten chronischen Nephrotoxizität durchgeführt, wenngleich sich dies aufgrund des sich etablierenden Konzepts einer nierenschonenden Langzeitimmunsuppression in Zukunft ändern dürfte. Im Vergleich zur KALT gestaltet sich die Indikationsstellung zur CLKT zumeist schwieriger, da standardisierte Kriterien fehlen. Die Indikation muss daher in enger Zusammenarbeit aller beteiligten Fachdisziplinen gestellt werden, um in Zeiten allgemeiner Organknappheit unnötige Doppeltransplantationen bei Patienten mit reversibler Nierenfunktionsstörung zu vermeiden. Beim hepatorenalen Syndrom sollte eine CLKT nur bei einer GFR unter 20 ml/min über mehr als 3 Monate oder einer mehr als 1-monatigen Dialysepflichtigkeit in Betracht gezogen werden. Protektive immunologische Effekte des Lebertransplantats für das Nierentransplantat sind vor allem bei der CLKT zu vermuten.

Abstract

Combined liver-kidney transplantations (CLKT) and kidney after liver transplantations (KALT) are established treatments for patients with end-stage hepatic and renal disease and the number of transplantations has continuously increased over the past few years. The most frequent indications for CLKT in adults are polycystic kidney disease with severe liver involvement and liver cirrhosis of different origins with concomitant chronic kidney failure due to chronic glomerulonephritis or diabetic nephropathy. In children, CLKT is most frequently required due to primary oxalosis type I. At present the main indication for KALT still is calcineurin inhibitor-induced chronic nephrotoxicity, emphasizing the need for a nephron-sparing long-term immunosuppression in liver transplant recipients. Compared to KALT, the indications for CLKT are not as well defined and the decision must therefore be made on a case-by-case basis by a multidisciplinary team of experienced clinicians to avoid unnecessary transplantations of both organs in patients with reversible kidney failure, given the scarcity of organs for transplantation worldwide. In hepatorenal syndrome CLKT should only be considered if the GFR is lower than 20 ml/min for more than three months or if the patient has been on renal replacement treatment for more than one month. In CLKT, there appears to be a certain immunological protection for the kidney transplant by the liver transplant.

Schlüsselwörter

Kombinierte Leber-Nieren-Transplantation - Sequentielle Leber-Nieren-Transplantation - Hepatorenales Syndrom - Primäre Hyperoxalurie Typ 1 - Polyzystische Nierenerkrankung - Kalzineurininhibitor-induzierte chronische Nephrotoxizität - Simultane Leber-Nierentransplantation

Keywords

combined liver-kidney transplantation - kidney after liver transplantation - hepatorenal syndrome - primary oxalosis type I - polycystic kidney disease - calcineurin inhibitor-induced chronic nephrotoxicity - simultaneous liver-kidney transplantation

Literatur

• 1 Abouchacra S, Toumeh S, Boobes Y, Bernieh B, Gorka W. An atypical course of Caroli’s disease in a renal transplant patient – case report and review of the literature.  Clin Nephrol. 2004;  61 282-288
• 2 Belghiti J, Panis Y, Sauvanet A, Gayet B, Fekete F. A new technique of side to side caval anastomosis during orthotopic hepatic transplantation without inferior vena caval occlusion.  Surg Gynecol Obstet. 1992;  175 270-272
• 3 Broyer M, Brunner F P, Brynger H. et al . Kidney transplantation in primary oxalosis: data from the EDTA Registry.  Nephrol Dial Transplant. 1990;  5 332-336
• 4 Burra P, Senzolo M, Masier A. et al . Factors influencing renal function after liver transplantation. Results from the MOST, an international observational study.  Dig Liver Dis. 2009;  41 350-356
• 5 Chava S P, Singh B, Pal S, Dhawan A, Heaton N D. Indications for combined liver and kidney transplantation in children.  Pediatr Transplant. 2009;  13 661-669
• 6 Chava S P, Singh B, Zaman M B, Rela M, Heaton N D. Current indications for combined liver and kidney transplantation in adults.  Transplant Rev (Orlando). 2009;  23 111-119
• 7 Chuang T W, Hung C H, Huang S C, Lee C M. Complete remission of nephrotic syndrome of hepatitis B virus-associated membranous glomerulopathy after lamivudine monotherapy.  J Formos Med Assoc. 2007;  106 869-873
• 8 Creput C, Durrbach A, Samuel D. et al . Incidence of renal and liver rejection and patient survival rate following combined liver and kidney transplantation.  Am J Transplant. 2003;  3 348-356
• 9 Demirci G, Becker T, Nyibata M. et al . Results of combined and sequential liver-kidney transplantation.  Liver Transpl. 2003;  9 1067-1078
• 10 Dikow R, Degenhard M, Kraus T. et al . Blood pressure profile and treatment quality in liver allograft recipients-benefit of tacrolimus versus cyclosporine.  Transplant Proc. 2004;  36 1512-1515
• 11 Fraley D S, Burr R, Bernardini J. et al . Impact of acute renal failure on mortality in end-stage liver disease with or without transplantation.  Kidney Int. 1998;  54 518-524
• 12 Gonwa T A, Jennings L, Mai M L. et al . Estimation of glomerular filtration rates before and after orthotopic liver transplantation: evaluation of current equations.  Liver Transpl. 2004;  10 301-309
• 13 Gonwa T A, Mai M L, Melton L B. et al . End-stage renal disease (ESRD) after orthotopic liver transplantation (OLTX) using calcineurin-based immunotherapy: risk of development and treatment.  Transplantation. 2001;  72 1934-1939
• 14 Gonwa T A, Morris C A, Goldstein R M, Husberg B S, Klintmalm G B. Long-term survival and renal function following liver transplantation in patients with and without hepatorenal syndrome – experience in 300 patients.  Transplantation. 1991;  51 428-430
• 15 Haberal M, Abbasoglu O, Buyukpamukcu N. et al . Combined liver-kidney transplantation from a living-related donor.  Transplant Proc. 1993;  25 2211-2213
• 16 Hanish S I, Samaniego M, Mezrich J D. et al . Outcomes of simultaneous liver/kidney transplants are equivalent to kidney transplant alone: a preliminary report.  Transplantation. 2010;  90 52-60
• 17 Kamath P S, Wiesner R H, Malinchoc M. et al . A model to predict survival in patients with end-stage liver disease.  Hepatology. 2001;  33 464-470
• 18 Kasahara M, Horikawa R, Tagawa M. et al . Current role of liver transplantation for methylmalonic acidemia: a review of the literature.  Pediatr Transplant. 2006;  10 943-947
• 19 Kirchner G I, Rifai K, Cantz T. et al . Outcome and quality of life in patients with polycystic liver disease after liver or combined liver-kidney transplantation.  Liver Transpl. 2006;  12 1268-1277
• 20 Koppel M H, Coburn J W, Mims M M. et al . Transplantation of cadaveric kidneys from patients with hepatorenal syndrome. Evidence for the functionalnature of renal failure in advanced liver disease.  N Engl J Med. 1969;  280 1367-1371
• 21 Labrune P. Glycogen storage disease type I: indications for liver and/or kidney transplantation.  Eur J Pediatr. 2002;  161 Suppl 1 S53-55
• 22 Lobato L, Ventura A, Beirao I. et al . End-stage renal disease in familial amyloidosis ATTR Val30Met: a definitive indication to combined liver-kidney transplantation.  Transplant Proc. 2003;  35 1116-1120
• 23 Loreno M, Boccagni P, Rigotti P, Naccarato R, Burra P. Combined liver-kidney transplantation in a 15-year-old boy with alpha1-antitrypsin deficiency.  J Hepatol. 2002;  36 565-568
• 24 Malla I, Lysy P A, Godefroid N. et al . Two-step transplantation for primary hyperoxaluria: cadaveric liver followed by living donor related kidney transplantation.  Pediatr Transplant. 2009;  13 782-784
• 25 Margreiter R, Konigsrainer A, Spechtenhauser B. et al . Our experience with combined liver-kidney transplantation: an update.  Transplant Proc. 2002;  34 2491-2492
• 26 Margreiter R, Kramar R, Huber C. et al . Combined liver and kidney transplantation.  Lancet. 1984;  1 1077-1078
• 27 Mehrabi A, Fonouni H, Ayoub E. et al . A single center experience of combined liver kidney transplantation.  Clin Transplant. 2009;  23 Suppl 21 102-114
• 28 Mehrabi A, Mood Z A, Fonouni H. et al . A single-center experience of 500 liver transplants using the modified piggyback technique by Belghiti.  Liver Transpl. 2009;  15 466-474
• 29 Mjornstedt L, Friman S, Backman L, Rydberg L, Olausson M. Combined liver and kidney transplantation against a positive cross match in a patient with multispecific HLA-antibodies.  Transplant Proc. 1997;  29 3164-3165
• 30 Monico C G, Milliner D S. Combined liver-kidney and kidney-alone transplantation in primary hyperoxaluria.  Liver Transpl. 2001;  7 954-963
• 31 Nair S, Verma S, Thuluvath P J. Pretransplant renal function predicts survival in patients undergoing orthotopic liver transplantation.  Hepatology. 2002;  35 1179-1185
• 32 Nakamura M, Fuchinoue S, Nakajima I. et al . Three cases of sequential liver-kidney transplantation from living-related donors.  Nephrol Dial Transplant. 2001;  16 166-168
• 33 Neumann U P, Lang M, Moldenhauer A. et al . Significance of a T-lymphocytotoxic crossmatch in liver and combined liver-kidney transplantation.  Transplantation. 2001;  71 1163-1168
• 34 Olausson M, Mjornstedt L, Norden G. et al . Auxiliary liver and combined kidney transplantation prevents hyperacute kidney rejection in highly sensitized patients.  Transplant Proc. 2002;  34 3106-3107
• 35 Oosterlee A, Rahmel A. Eurotransplanz International Annual Report 2009. 2010: 37-40
• 36 Paradis K. Tyrosinemia: the Quebec experience.  Clin Invest Med. 1996;  19 311-316
• 37 Prokurat S, Grenda R, Lipowski D, Kalicinski P, Migdal M. MARS procedure as a bridge to combined liver-kidney transplantation in severe chromium-copper acute intoxication: a paediatric case report.  Liver. 2002;  22 Suppl 2 76-77
• 38 Remuzzi G, Ruggenenti P, Codazzi D. et al . Combined kidney and liver transplantation for familial haemolytic uraemic syndrome.  Lancet. 2002;  359 1671-1672
• 39 Ruiz R, Barri Y M, Jennings L W. et al . Hepatorenal syndrome: a proposal for kidney after liver transplantation (KALT).  Liver Transpl. 2007;  13 838-843
• 40 Ruiz R, Jennings L W, Kim P. et al . Indications for combined liver and kidney transplantation: propositions after a 23-yr experience.  Clin Transplant. 2009;  DOI: 10.1111/j.1399-0012.2009.01180.x
• 41 Salizzoni M, Gennari F, Liddo G. et al . Sequential liver-kidney transplantation.  Transplant Proc. 2004;  36 543-544
• 42 Schmitt T M, Kumer S C, Al-Osaimi A. et al . Combined liver-kidney and liver transplantation in patients with renal failure outcomes in the MELD era.  Transpl Int. 2009;  22 876-883
• 43 Shapiro R, Weismann I, Mandel H. et al . Primary hyperoxaluria type 1: improved outcome with timely liver transplantation: a single-center report of 36 children.  Transplantation. 2001;  72 428-432
• 44 Shusterman B, McHedishvili G, Rosner M H. Outcomes for hepatorenal syndrome and acute kidney injury in patients undergoing liver transplantation: a single-center experience.  Transplant Proc. 2007;  39 1496-1500
• 45 Simpson N, Cho Y W, Cicciarelli J C, Selby R R, Fong T L. Comparison of renal allograft outcomes in combined liver-kidney transplantation versus subsequent kidney transplantation in liver transplant recipients: Analysis of UNOS Database.  Transplantation. 2006;  82 1298-1303
• 46 Starzl T E, Marchioro T L, Vonkaulla K N. et al . Homotransplantation of the Liver in Humans.  Surg Gynecol Obstet. 1963;  117 659-676
• 47 Tzakis A, Todo S, Starzl T E. Orthotopic liver transplantation with preservation of the inferior vena cava.  Ann Surg. 1989;  210 649-652
• 48 Uemura T, Sanchez E Q, Ikegami T. et al . Successful combined liver and kidney transplant for COACH syndrome and 5-yr follow-up.  Clin Transplant. 2005;  19 717-720
• 49 Van Wagner L B, Baker T, Ahya S N. et al . Outcomes of patients with hepatitis C undergoing simultaneous liver-kidney transplantation.  J Hepatol. 2009;  51 874-880
• 50 Wahlin S, Harper P, Sardh E. et al . Combined liver and kidney transplantation in acute intermittent porphyria.  Transpl Int. 2009;  23 e18-21
• 51 Zacks S L, Fried M W. Hepatitis B and C and renal failure.  Infect Dis Clin North Am. 2001;  15 877-899