Dual Liver and Kidney Transplantations

Tips from the NKF 2010 sessions


1. When to do both and when to do just Liver? It’s hard to figure this out as most of the kidney damage in liver associated kidney injury is ischemia and we don’t have good markers
2. A good strategy suggested was using biopsy as a guide and using the Interstitial fibrosis, tubular injury as a tool for seeing if they need a SLK or just a liver transplant.
3. When this strategy was used in some centers, and crt compared after going ahead with a respective transplants ( SLK or just liver), crt were 1.2 at 6 months in both groups.
4. Most common biopsy finding: ischemic ATN, followed by other primary GNs, (MPGN, IgA, FSGS, TMA) and vascular disease
5. If the patient has ESLD and is on dialysis < 6 weeks, perhaps just a liver is fine but otherwise might need a SLK. But with the biopsy method, we might achieve more accuracy

HIV and the Kidney Transplant

What I learned at the NKF 2010 , some few points.


1. A large NIH sponsored study basically showed that the outcomes of large number of patients when compared to non hiv patients transplanted was no different.
2. The 3 year follow up showed no major difference in graft survival
3. HIV disease didn’t progress either, perhaps because they didn’t get induction therapy or they were carefully selected patients or there is data that almost all immunosuppresive drugs we use has anti HIV viral activity from cellcept to CNI to sirolimus
4. The major problems people run into these transplants are drug toxicities as anti retrovirals have significant effect on CNI levels and high doses of CNI and increased intervals are needed.
5. There is usually more rejection in these patients,perhaps because of point number 5, but also perhaps because they don’t get much induction
6. Some centers are using induction with thymo, but their acute bacterial infection rates are high. Ideally, a anti CD20 induction is a good choice.


A nice website to look at is: hivtransplant.com

Obesity and Kidney Transplantation

What I learned at the NKF 2010. Some key points

1. BMI < 18 and >30 are both associated with worsening graft survival
2. Why does obesity affect transplant outcomes: The risk factors after few studies have been: increased insulin resistance, increased BP, hyperlipidemia, increased proteinuria and development of NODAT

3. There has been a higher incidence of acute rejection in high BMI patients? The reason: obesity has been associated with mild continuous chronic inflammation and increased proteinuria.

4. Should obese patients be trasnplanted? Yes as a comparative study showing how they do on dialysis still shows they do better on transplant. Yes, when compared to non obese patients getting transplanted, the risk is low, the overall benefit vs dialysis is more.
5. Should their immunosuppresion be treated differently? No real headway. When compared steroid free vs steroid + protocols in obese patients, no difference was noted in outcomes.