engleski

Biopsy Guided Evaluation in Patients with Renal Impairment Awaiting Liver Transplantation- How Kidney Biopsies Save Organs

Background: After the introduction of MELD score in liver allocation, the number of simultaneous liver- kidney transplantations (SLKT) significantly increased therefore contributing to the shortage of allografts for patients waitlisted for kidney transplantation. We analyzed the data in our high- volume transplant center with a stable number of SLKT and reviewed our biopsy-guided kidney allocation policy in pts with renal dysfunction undergoing liver transplantation (LT). Methods: We analyzed LT and SLKT performed in UH Merkur, Croatia from April 2007 to April 2018. As significant renal impairment at time of enlisting we defined serum creatinine higher or equal to 2 mg/dL, renal replacement therapy (RRT) or pathologic proteinuria higher than p/c 1 g/g. Results: In total 1056 LT and 19 SLKT were identified. 129 pts fulfilled the criteria for renal impairment given above. There were 95 male pts (73, 6%). 13 patients had ESRD receiving RRT prior to referral for LT and were automatically enlisted for SLKT. From those 13, in 2 pts SLKT was performed because of primary hyperoxaluria. In evaluation of other pts with renal dysfunction 22 renal biopsies were performed under US guidance after correction of coagulation parameters. There were no major complications of biopsies. Other 94 pts were diagnosed with acute kidney injury/hepatorenal syndrome (AKI/HRS). The most common pathohistological diagnosis was IgA nephropathy (63, 6%), followed by ATN (18, 2%) and diabetic nephropathy (9, 1%). The cut-off for SLKT was more than 40% interstitial fibrosis and tubule atrophy (IFTA), or more than 30% of globally sclerosed glomeruli (GS) on biopsy. Based on biopsy results additional 6 pts were enlisted for SLKT. None of the patients with presumed AKI/HRS who received only LT and survived for more than one- month post-LT required RRT at one-month post-LT. Conclusions: We believe that kidney biopsy is a useful and safe tool to avoid kidney graft wasting when evaluating enlistment for SLKT. We enlist a patient for SLKT if IFTA is higher than 40% or GS more than 30%. A separate indication for SLKT are metabolic diseases. In decompensated liver cirrhosis HRS develops and makes evaluation of kidney recovery potential speculative. In our experience, percutaneous kidney biopsy in pts with advanced liver disease was not linked to adverse events and is a safe procedure in experienced centers.

liver transplantation, kideny biopsy, hepatorenal syndrome, simultaneous liver kidney transplantation

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