Search

Aim We report a series of patients who underwent combined heart-kidney transplantation (CHKT) and combines liver-kidney transplantation (CLKT) at a single center. Methods From January 1997 to October 2004, 13 CLKT and 2 CHKT were performed. The CLKT indications were as follows: polycystic disease (2), kidney polycystic disease associated with Caroli (1) and cirrhosis–hepatitis C virus (HCVs) (1), chronic glomerulonephritis with cirrhosis-HCV (4), and other diseases (5). From December 2003 to October 2004, 2 patients underwent CHKT for idiopathic cardiomyopathy plus glomerulonephritis and ischemic cardiomyopathy associated with vascular nephritis. Results In the CLKT group, 1 patient had acute rejection involving both liver and kidney grafts, whereas 1 patient had liver rejection and another 1 had kidney rejection alone. Of the 13 patients, 10 are alive with a mean survival of 583 days (range, 36–2688 days); 2 patients died within 1 month of transplantation (both with polycystic disease) due to ARDS and MOF. Another patient died 6 years and 9 months after CLKT of metastasis from a de novo tumor. In the CHKT group, no patient suffered heart-kidney rejection. They are all alive at 333 and 116 days, with heart and kidney allografts functioning well. Conclusion In the CLKT group, the worst results were for patients with polycystic disease, in whom a more rigorous selection is necessary because of greater technical difficulties. For the remaining patients we had acceptable complications and excellent long-term results. In selected cases, CHKT can provide long-term graft function and patient survival. Our experience indicates that end-stage kidney failure combined with liver or heart failure does not necessarily preclude dual-organ transplantation.

Background We retrospectively reviewed our experience in combined liver–kidney (L-KT) and heart–kidney (H-KT) transplantations. Patients and Methods Between January 1997 and April 2007, we performed 25 L-KT and 5 H-KT. Patient mean age was 51 ± 8 years in L-KT and 43 ± 11 years in H-KT. The main cause of liver failure was chronic viral hepatitis (14 cases). Etiology of heart failure was dilated cardiomyopathy and hypertrophic cardiomyopathy (4 and 1 patients, respectively). The main causes of renal failure in L-KT were chronic glomerulonephritis (n = 8) and polycystic disease (n = 7). Etiology of renal failure in H-KT was interstitial nephropathy (n = 2), vascular nephropathy (n = 2), and chronic glomerulonephritis (n = 1). Results Mean follow-up was 32 ± 26 months in L-KT and 24 ± 17 months in H-KT. Immunosuppression was cyclosporine-based (n = 4) or tacrolimus-based (n = 21) in L-KT and cyclosporine-based in H-KT. Acute rejection rate was 8% for both liver and kidney in L-KT; 80% (mild) for heart and 40% for kidney in H-KT. In the L-KT group, there was no primary graft nonfunction (PGNF). Two patients experienced liver delayed graft function (DGF); 1 patient required postoperative dialysis. One-year graft and patient survivals were both 84% and overall graft and patient survival was 76%. In the H-KT group, 3 patients needed postoperative dialysis and 1 required a cardiac assistance device for 48 hours; overall graft and patient survival was 100% with good cardiac and renal functions. Conclusion Our experience confirmed that H-KT and L-KT are safe procedures, offering good long-term results.

A 22-year-old man was admitted to our hospital for progressive liver failure with ascites, jaundice, and bleeding from esophagogastric varices due to chronic Budd-Chiari syndrome and antiphospholipid syndrome. Nine years before, a transjugular intrahepatic portosystemic shunt (TIPS) had been placed between the right hepatic vein and the portal vein at another hospital. The patient subsequently developed acute obstruction of the hepatic veins followed by the progressive upward extension of the thrombus, requiring positioning of a second TIPS in the vena cava. Because of complete occlusion of both shunts, the patient developed the symptoms of chronic Budd-Chiari syndrome despite collateral circulation. At our hospital, a computed tomography scan confirmed the presence of a thrombus in the vena cava from the renal veins to the right atrium (Fig. 1). The patient was scheduled for liver and partial right atrium transplantation with cardiopulmonary bypass. The abdominal incision started when the ascending aorta, the superior vena cava, and the right femoral vein had been cannulated and normothermic cardiopulmonary bypass had been instituted. This strategy helped us to decompress the portal vein and the collateral circulation and permitted an easier approach to the right atrium. The recipient hepatectomy was performed with the resection of the vena cava from the renal veins to the right atrium and with the opening of the diaphragm through the central fibrous body (Fig. 2). Occlusion of the caval lumen up to the right atrium was confirmed (Fig. 3A,B). The graft was retrieved from a 66-year-old woman considered to be not suitable for heart donation; this allowed us to harvest the liver with the right atrium en bloc (Fig. 4A). In the recipient, the donor atrium was brought into the chest through the diaphragm for the atriumatrium anastomosis (white circle in Fig. 4B). The anastomosis of the inferior vena cava, portal vein, hepatic artery, and bile duct was performed in a standard fashion. During the procedure, hemodynamic parameters remained stable, the cold ischemia time was 7 hours, and 12 units of packed red blood cells were required. The postoperative course was uneventful, and the patient was discharged after 4 weeks. We believe that the key point for the success of this procedure was the planning of liver and partial atrium transplantation with cardiopulmonary bypass. The use of the donor atrium ensured enough tissue to remove the recipient vena cava together with the portion of the atrium affected by the thrombus and easy accomplishment of the atrium-atrium anastomosis. The cardiopulmonary bypass and the partial atrium transplantation due to the atrium being affected by the thrombus, reported in other cases, permitted optimal management of the intraoperative hemodynamic conditions, counterbalancing the need for heparin infusion during extracorporeal circulation.