Original Clinical Science
Outcomes of Liver Transplantation Alone After Listing for Simultaneous Kidney: Comparison to Simultaneous Liver Kidney Transplantation Bashar Hmoud,1 Yong-Fang Kuo,2 Russell H. Wiesner,3 and Ashwani K. Singal4 Background. Data on patient and liver graft survival comparing liver transplantation alone after listing for kidney with simultaneous liver kidney (SLK) transplantation are scanty. Methods. United Network Organ Sharing network database (1994–2011) queried for liver transplantation alone after being listed for kidney and SLK transplants. Results. Of 65,206 first liver transplants,
3549 were listed for simultaneous kidney. Of these, 422 (12%) received only liver (LIST) and differed from SLK recipients for the white race (64% vs. 57%; 0.005), diabetes (27% vs. 37%; P = 0.02), model for end-stage liver disease era (68% vs. 82%; P = 0.0001), serum creatinine (2.9±1.9 vs. 4.3±2.5; P < 0.0001), dialysis (35% vs. 64%; P < 0.0001), and donor risk index (1.6±0.4 vs. 1.5±0.3; P < 0.0001). Overall survival was poorer in the LIST group (55% vs. 76%; P < 0.0001). A higher proportion of patients died within 2 days of transplantation in LIST group (11% vs. 0.5%; P < 0.0001), mostly from cardiovascular causes. After excluding these patients, odds of patient mortality and liver graft loss were about 1.2-fold and twofold higher in the LIST group. A total of 103 (24%) patients needed a renal transplantation in the LIST group with 16 (4%) receiving kidney within first year after transplantation. After excluding patients receiving kidney within first year, about 33% recovered renal function to above estimated GFR of greater than 60 mL per min. Conclusion. Guidelines are needed for patient selection to list for and receipt of simultaneous liver kidney transplantation. (Transplantation 2015;99: 823–828)
R
enal insufficiency occurs in about 25% to 30% of patients in patients with cirrhosis who are listed for liver transplantation and is associated with poor posttransplant outcomes.1-6 Many of these patients would require simultaneous liver and kidney (SLK) transplantation to improve
Received 13 May 2014. Revision requested 4 June 2014. Accepted 25 July 2014. 1
Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX.
2
Department of Biostatistics, University of Texas Medical Branch, Galveston, TX.
3
Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
4
Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, AL.
This study received grant and financial support from the UAB Comprehensive Transplant Institute Angus Cooper Award. The authors declare no conflicts of interest. S.H. contributed to data compilation and writing the initial draft of the article. Y.-F.K. contributed to statistical analysis and writing the statistical section of the article. R.H. W. contributed to study design and approving the final draft of the article. A.K.S. contributed to study design, data analysis, and writing and approving the final draft of the article. Correspondence: Ashwani K. Singal, MD, MS, Division of Gastroenterology and Hepatology, University of Alabama Birmingham, AL 35294-0012. (ashwanisingal. [email protected]). Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.transplantjournal.com). Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0041-1337/15/9904/823 DOI: 10.1097/TP.0000000000000438
Transplantation
■
April 2015
■
Volume 99
■
Number 4
outcomes.6,7 Guidelines on allocating SLK in these patients are based on consensus opinion and lack sufficient evidence.8 This along with implementation of model for end-stage liver disease (MELD) score to aid organ allocation for patients with end-stage liver disease has resulted in a huge increase in use of SLK.6,9,10 About 10% of patients listed for SLK receive liver alone.11,12 Data remain unclear on posttransplant outcomes of these patients compared to patients receiving SLK. We performed this study using the United Network for Organ Sharing (UNOS) database to examine outcomes of SLK transplants to patients listed for SLK but receiving liver alone. RESULTS Study Population and Frequency of Transplants
Of the 3,549 patients listed for simultaneous kidney, 3,127 received SLK transplantation, and 422 (12%) received liver alone (LIST) (Figure S1, SDC, http://links.lww.com/TP/B62). Of patients listed for simultaneous kidney, proportion in the LIST group fluctuated in the pre-MELD era, but showed decreasing trend in the MELD era from about 15% during 2003 to 2005 to about 9% during 2009 to 2011 (Figure S2, SDC, http://links.lww.com/TP/B62). Baseline Characteristics
LIST group as compared to SLK differed for higher proportion of Caucasians and being on ventilator at the time of transplantation and received slightly higher risk liver graft. In contrast, LIST group had lower proportion with diabetes, renal insufficiency (serum creatinine > 2 mg/dL), and being www.transplantjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
823
824
Transplantation
■
April 2015
■
Volume 99
■
Number 4
www.transplantjournal.com
TABLE 1.
Baseline characteristics comparing patients receiving liver alone after being listed for simultaneous kidney (LIST) and patients receiving simultaneous liver kidney (SLK) transplantation
Age, yr (mean±SD) Male sex, % Caucasian race, % Diabetes mellitus, % On ventilator, % Transplants in MELD era, % MELD score (mean±SD) Serum creatinine, mg/dL Serum creatinine >2 mg/dL, % On dialysis, % Median (range) Donor risk index
LIST (N = 422)
SLK (N = 3127)
P
53 ± 10 63 64 29 7 68 29 ± 10 2.9 ± 1.9 56 35 1.48 (0.97-2.87)
54 ±10 66 57 37 5 82 29 ± 9 4.3 ± 2.5 85 64 1.41 (0.98-3.83)
0.36 0.12 0.005 0.023 0.036 0.0001 0.14
Outcomes of Liver Transplantation Alone After Listing for Simultaneous Kidney: Comparison to Simultaneous Liver Kidney Transplantation Bashar Hmoud,1 Yong-Fang Kuo,2 Russell H. Wiesner,3 and Ashwani K. Singal4 Background. Data on patient and liver graft survival comparing liver transplantation alone after listing for kidney with simultaneous liver kidney (SLK) transplantation are scanty. Methods. United Network Organ Sharing network database (1994–2011) queried for liver transplantation alone after being listed for kidney and SLK transplants. Results. Of 65,206 first liver transplants,
3549 were listed for simultaneous kidney. Of these, 422 (12%) received only liver (LIST) and differed from SLK recipients for the white race (64% vs. 57%; 0.005), diabetes (27% vs. 37%; P = 0.02), model for end-stage liver disease era (68% vs. 82%; P = 0.0001), serum creatinine (2.9±1.9 vs. 4.3±2.5; P < 0.0001), dialysis (35% vs. 64%; P < 0.0001), and donor risk index (1.6±0.4 vs. 1.5±0.3; P < 0.0001). Overall survival was poorer in the LIST group (55% vs. 76%; P < 0.0001). A higher proportion of patients died within 2 days of transplantation in LIST group (11% vs. 0.5%; P < 0.0001), mostly from cardiovascular causes. After excluding these patients, odds of patient mortality and liver graft loss were about 1.2-fold and twofold higher in the LIST group. A total of 103 (24%) patients needed a renal transplantation in the LIST group with 16 (4%) receiving kidney within first year after transplantation. After excluding patients receiving kidney within first year, about 33% recovered renal function to above estimated GFR of greater than 60 mL per min. Conclusion. Guidelines are needed for patient selection to list for and receipt of simultaneous liver kidney transplantation. (Transplantation 2015;99: 823–828)
R
enal insufficiency occurs in about 25% to 30% of patients in patients with cirrhosis who are listed for liver transplantation and is associated with poor posttransplant outcomes.1-6 Many of these patients would require simultaneous liver and kidney (SLK) transplantation to improve
Received 13 May 2014. Revision requested 4 June 2014. Accepted 25 July 2014. 1
Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX.
2
Department of Biostatistics, University of Texas Medical Branch, Galveston, TX.
3
Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
4
Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, AL.
This study received grant and financial support from the UAB Comprehensive Transplant Institute Angus Cooper Award. The authors declare no conflicts of interest. S.H. contributed to data compilation and writing the initial draft of the article. Y.-F.K. contributed to statistical analysis and writing the statistical section of the article. R.H. W. contributed to study design and approving the final draft of the article. A.K.S. contributed to study design, data analysis, and writing and approving the final draft of the article. Correspondence: Ashwani K. Singal, MD, MS, Division of Gastroenterology and Hepatology, University of Alabama Birmingham, AL 35294-0012. (ashwanisingal. [email protected]). Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.transplantjournal.com). Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0041-1337/15/9904/823 DOI: 10.1097/TP.0000000000000438
Transplantation
■
April 2015
■
Volume 99
■
Number 4
outcomes.6,7 Guidelines on allocating SLK in these patients are based on consensus opinion and lack sufficient evidence.8 This along with implementation of model for end-stage liver disease (MELD) score to aid organ allocation for patients with end-stage liver disease has resulted in a huge increase in use of SLK.6,9,10 About 10% of patients listed for SLK receive liver alone.11,12 Data remain unclear on posttransplant outcomes of these patients compared to patients receiving SLK. We performed this study using the United Network for Organ Sharing (UNOS) database to examine outcomes of SLK transplants to patients listed for SLK but receiving liver alone. RESULTS Study Population and Frequency of Transplants
Of the 3,549 patients listed for simultaneous kidney, 3,127 received SLK transplantation, and 422 (12%) received liver alone (LIST) (Figure S1, SDC, http://links.lww.com/TP/B62). Of patients listed for simultaneous kidney, proportion in the LIST group fluctuated in the pre-MELD era, but showed decreasing trend in the MELD era from about 15% during 2003 to 2005 to about 9% during 2009 to 2011 (Figure S2, SDC, http://links.lww.com/TP/B62). Baseline Characteristics
LIST group as compared to SLK differed for higher proportion of Caucasians and being on ventilator at the time of transplantation and received slightly higher risk liver graft. In contrast, LIST group had lower proportion with diabetes, renal insufficiency (serum creatinine > 2 mg/dL), and being www.transplantjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
823
824
Transplantation
■
April 2015
■
Volume 99
■
Number 4
www.transplantjournal.com
TABLE 1.
Baseline characteristics comparing patients receiving liver alone after being listed for simultaneous kidney (LIST) and patients receiving simultaneous liver kidney (SLK) transplantation
Age, yr (mean±SD) Male sex, % Caucasian race, % Diabetes mellitus, % On ventilator, % Transplants in MELD era, % MELD score (mean±SD) Serum creatinine, mg/dL Serum creatinine >2 mg/dL, % On dialysis, % Median (range) Donor risk index
LIST (N = 422)
SLK (N = 3127)
P
53 ± 10 63 64 29 7 68 29 ± 10 2.9 ± 1.9 56 35 1.48 (0.97-2.87)
54 ±10 66 57 37 5 82 29 ± 9 4.3 ± 2.5 85 64 1.41 (0.98-3.83)
0.36 0.12 0.005 0.023 0.036 0.0001 0.14
