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• W2948720561 abstract "The field of kidney transplantation (KTx) has evolved with hypothermic machine perfusion (HMP) to extend the time between procurement and transplant, expanding the shipping distance (eg, East-to-West Coast in the US). HMP also enabled the limitation of the harmful effect of cold ischemia time (CIT) and therefore decreased the rate of delayed graft function (DGF).1 Studies on long-term effects of CIT showed a proportional increase in DGF and graft failure with each hour of CIT.2 In the case of combined liver-KTx (CLKTx), the recipient is critically ill with coagulopathy, hyperbilirubinemia, and on pressor(s) support immediately after liver transplantation (LTx), creating an unfavorable hostile environment for the kidney allograft. Therefore, it is preferable that KTx is delayed with the support of HMP.3 We previously showed a novel approach of delaying the kidney portion of CLKTx in a cohort of 61 patients with a mean CIT of 50 hours (range 20–81 hours) with excellent outcomes in patient survival.3,4 Our studies confirmed that DGF is the most important negative predictor of patient survival in this complex group of patients. Here, we are reporting a delayed KTx in CLKTx with a CIT of 83.3 hours (the longest reported in the literature). The recipient was a 54-year-old male with a history of chronic liver failure secondary to chronic autoimmune hepatitis, and chronic kidney disease on hemodialysis starting 3 months before transplant. His MELD score was 33. He was very frail, sarcopenic, and required biweekly paracenteses for significant ascites. He was frequently admitted for encephalopathy and required esophageal variceal banding and underwent fixation for a femoral neck fracture from a fall. In November 2017, he underwent LTx from a 47-year-old male donor who died of stroke (Figure 1). The patient was supported by continuous veno-venous hemodialysis intraoperatively until delayed KTx (routine for our CLKTx patients). Donor-calculated kidney donor profile index was 71% with a positive crossmatch. Due to the requirement of significant vasopressor support post-LTx, KTx was delayed for 83.3 hours. The patient developed acute tubular necrosis post-KTx, confirmed by renal biopsy. Six months after CLKTx, the patient came off of hemodialysis. In order to confirm the residual function of native kidneys, a renal scan was performed and confirmed the sole function of the transplanted kidney (Figure 1). At 1-year follow-up, both his liver and kidney have good function. This case demonstrates the amazing capacity of renal allograft to recover its function despite multiple insults in a hostile environment, even 6 months after CLKTx. We believe that the most likely mechanism of delayed graft recovery was the significant initial insult due to: (1) high bilirubin that crystalized in the renal tubules; (2) high pressor needs; and (3) overall weak and sarcopenic status of the recipient. With the recent advancement in normothermic machine perfusion,5 future studies comparing hypothermic and normothermic machine perfusions in KTx will be valuable not only in KTx alone but also in CLKTx.FIGURE 1.: Time course from combined liver-delayed kidney transplant to 12-month follow-up. A, Description of important events in pretransplant, peritransplant, and posttransplant. Liver transplant surgery (POD0) was very difficult due to adhesions, scarring of the cirrhotic liver, and thrombocytopenia, requiring 30 units packed red blood cells, 16 units fresh frozen plasma, and 3 units platelets. His immediate postoperative course was complicated, requiring multiple pressor support and reintubations for pulmonary edema and altered mentation. The patient started on CVVH on POD12. A kidney biopsy on POD42 confirmed the ATN. Post biopsy, he developed a perinephric intraperitoneal hematoma requiring transfusion and operative exploration. In April 2018, his right inguinal hernia was repaired—by this time, he had improving urine output and creatinine and was trialed off of hemodialysis after surgery. B, Renal scan 6 months after the transplant showing activity on the transplanted kidney in the left iliac fossa. C, Native kidneys (studied exclusively in this figure) showed no uptake of radioactive material, indicating no function of native kidneys and confirming that renal function and creatinine clearance only depend on the transplanted kidney. *CVVH dialysis started, which eventually converted to intermittent hemodialysis. #The patient’s renal function recovered, and he was completely off hemodialysis. Apr-18, April 2018; ATN, acute tubular necrosis; CVVH, continuous veno-venous hemofiltration; CCC, calculated creatinine clearance according to Cockcroft-Gault formula, Dec-17, December 2017; HD, hemodialysis; IHR, inguinal hernia repair; KTx, kidney transplant; mo, month posttransplant; Nov-17, November 2017; OLTx, orthotopic liver transplant; POD, postoperative day; s-Cre, serum creatinine." @default.
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• W2948720561 date "2019-02-01" @default.
• W2948720561 modified "2023-09-26" @default.
• W2948720561 title "DELAYED KIDNEY TRANSPLANTATION AFTER 83 HOURS OF COLD ISCHEMIA TIME IN COMBINED LIVER-KIDNEY TRANSPLANT" @default.
• W2948720561 doi "https://doi.org/10.1097/00007890-900000000-96201" @default.
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