Combined Liver-Kidney Transplantation: When and How?

Combined Liver – Kidney Transplantation (CLKT) is a surgery where whole or a part of a liver and one or more kidneys are transplanted in a patient in the same setting.

Organ transplantation is a complex surgery. But After years of research and technological advances, these surgeries have become safer today. Kidney transplantation alone or liver transplantation alone is a major and complex surgery. So, performing these surgeries together in one go warrants advanced infrastructure and skilled doctors and nursing staff.

Indications of CLKT – when do you need it?

Patients need CLKT when they suffer from liver cirrhosis and chronic kidney disease as well and are on maintenance haemodialysis for CKD. Common kidney diseases like glomerulopathy (membranous, membranoproliferative, IgA nephropathy, Diabetes Mellitus), nephrolithiasis, polycystic disease, glomerulonephritis/glomerulopathy associated with viral hepatitis (HBV, HCV), HCV CLD in CKD patients on maintenance haemodialysis and others, when associated with liver cirrhosis need CLKT. Besides, there are some studies which suggest that liver cirrhosis patients with long standing hepatorenal syndrome (HRS) may have better outcome with CLKT than liver transplantation alone. Also, there is a subset of metabolic diseases which primarily affect kidneys, but liver serves as a gene therapy to correct the disorder like primary hyperoxaluria I, amyloidosis, haemolytic uremic syndrome, and others. Such patients need CLKT for cure of their metabolic disorder.

CLKT – How to do it?

CLKT is done in two ways:

1. Deceased donor (cadaveric) transplantation
2. Living donor transplantation

While the cadaveric CLKT utilizes organs from brain-dead donors, the living donor CLKT utilizes organs from living donors, generally, healthy, family relatives. The recipient gets one or two kidneys and whole (adult recipient)/part of liver (paediatric recipient) in a cadaveric transplant.  On the other hand, we need two separate donors for liver and kidney in living donor transplantation. The patient receives a part of liver and one kidney in living donor transplantation. However, the outcome of CLKT with either technique is similar.

Preoperative, intraoperative, and postoperative optimization are very important for a successful CLKT.

How to do CLKT – Preoperative optimisation

Liver cirrhosis patients tend to accumulate lot of fluid in third spaces in advanced stage, which causes pedal oedema, ascites, pleural effusion, pulmonary oedema, pulmonary hypertension, and other complications. Such patients with added renal dysfunction, are on a higher risk of such complications. So, they need preoperative optimization in form of fluid restriction, salt restriction, diuretics, regular dialysis (as advised by physician), and vitamin and mineral supplements. The patients must consult their physician regularly and follow their advice. Also, they must also consult a physiotherapist for lung optimization in form of respiratory exercises and physiotherapy.

How to do CLKT – Intraoperative challenges

CLKT is a challenging surgery because of long surgical duration, fluid shifts and need for experienced and skilled OT staff. Liver is transplanted first, followed by kidney transplantation through a separate incision. The surgery lasts for approximately 12-16 hours. A lot of fluid shifts happen during surgery. The surgery may need transfusions of blood and blood components. Also, fluid balance needs to be taken care of and as and when required and the patient may need dialysis during the surgery in some cases. Transplantation is a skill-intensive surgery and requires skilled surgeons, anaesthetists, and nursing staff.

How to do CLKT – Postoperative challenges

All organ transplantation patients need immunosuppression to prevent graft rejection postoperatively. However, the immunosuppression requirement is different for different organ transplantations – kidney transplantation needing more immunosuppression than liver transplantation. However, liver when transplanted along with other organs like kidney impart an immunoprotective effect. So, immunosuppression requirement in CLKT is usually less than kidney transplantation alone.

Once transplanted kidney starts functioning and producing urine, fluid replacement is very important to prevent early complications like acute tubular necrosis (ATN). This replacement needs to be done through intravenous route.

We manage the patients with CLKT with a goal of optimized long-term immunosuppression. The patients must follow up regularly with their treating physicians and must undergo liver function tests and kidney function tests and tests to assess the blood level of immunosuppressive medication on a regular interval. Also, they must take immunosuppression life long as advised by physician.

Conclusion

CLKT is a complex and major surgery. Selective patients need it. It has good outcomes but needs experienced surgeons, physicians, and good infrastructure.