S004: SINGLE-CENTER EXPERIENCE WITH SIMULTANEOUS LIVER-KIDNEY TRANSPLANTATION (SLKT): PERIOPERATIVE CONSIDERATIONS AND OUTCOMES
Nicolas P Caram, MD; Mariana Acosta, MD; Daniel Schmidt, MD; Marianfeli Landino, MD; Cosmin Guta, MD; Marina Gitman, MD; Ramona Nicolau-Raducu, MD, PhD; Fouad Souki, MD
Jackson Memorial Hospital / University of Miami
Background: The number of simultaneous liver-kidney transplants (SLKT) continues to rise among patients with cirrhosis and end-stage renal disease (ESRD) (1). Factors contributing to this increase include Model for End-stage Liver Disease (MELD)-based allocation, regional sharing for high MELD candidates, and the rising incidence of non-alcoholic steatohepatitis (NASH) with concurrent renal insufficiency (2). Given the complex perioperative management and potential complications, understanding the outcomes of SLKT is essential (3). This study presents a single-center experience analyzing SLKT recipient characteristics, intraoperative considerations, and post-operative outcomes.
Methods: A retrospective review of 150 adult SLKT recipients (90 male, 60 female) was conducted using a pre-existing liver transplant database maintained by the Abdominal Organ Transplant Anesthesia Department at Jackson Memorial Hospital, University of Miami. The electronic database contained information for all liver transplant recipients, including SLKT, between January 2016 and December 2024. Follow-up data were available until February 15, 2025.
Results: Of the 1,077 liver transplants performed during the study period, 150 (13.9%) were SLKTs. The mean age at transplantation was 59.6 years (SD 10.2), and the mean MELD score was 28.3 (SD 7.1). The most common indications for liver transplantation were NASH/cryptogenic disease (39%), alcoholic liver disease (20%), viral hepatitis (16%), and polycystic kidney disease (PKD) (12%). Pre-transplant dialysis was required by 71.3% of patients.
Intraoperatively, 61% of patients required massive transfusion (defined as >10 units of packed red blood cells [PRBCs]). Median intraoperative fluid administration included 4,500 mL crystalloid, 1,000 mL albumin, 12 units PRBCs, 8 units fresh frozen plasma, 2 units cryoprecipitate, and 2 units platelets. Intraoperative renal replacement therapy (RRT) was used in 92.7% of cases. In 82% of cases, the kidney was transplanted via a separate incision. Median cold ischemia times were 5.5 hours (SD 1.52) for the liver and 25.2 hours (SD 12.04) for the kidney. One patient was excluded from kidney transplantation due to hemodynamic instability following liver transplantation.
Post-transplant delayed kidney graft function (DGF), defined as the need for dialysis within the first week, occurred in 31.3% of patients. RRT dependence beyond one month was observed in 3.3% of recipients. Median bilirubin at 7 days was 3.19 mg/dL, and median INR at 7 days was 1.27. Six-month and one-year survival rates were 90.4% and 86.2%, respectively. The primary causes of death were sepsis in 82%, cardiac complications in 13%, and other causes in 5%.
Conclusions: Our findings highlight the complex perioperative management of these patients, including the high prevalence of pre-transplant dialysis, the frequent need for massive transfusion, and the common use of intraoperative RRT. While delayed graft function remains a significant post-transplant complication, the overall six-month and one-year survival outcomes following SLKT are excellent. These results reinforce SLKT as an effective treatment strategy for select patients with combined liver and kidney failure.
References:
- Macech M. Outcomes of Combined Liver-Kidney Transplantation. Transp Proceedings 2024.
- Miles CD. Simultaneous Liver-Kidney Transplantation: Impact on liver transplant patients and the kidney transplant waiting list. Current Trans Reports 2018.
- Nair G.Simultaneous Liver–Kidney Transplantation. Clinics in Liver Disease 2022.
