After Institutional Review Board approval was obtained, we performed a retrospective review of all adult, primary, deceased-donor, SLK transplants (n=37) performed between January 1, 1998 and December 31, 2008. We utilized the prospectively-collected transplant database at the University of Wisconsin. Outcomes were compared between recipients of DBD (n=32) and DCD organs (n=5).
All patients received dexamethasone or methylprednisolone at the time of implantation, and the majority was maintained on mycophenolate mofetil (CellCept, Roche) or mycophenolic acid (Myfortic, Novartis), steroids, and a calcineurin-inhibitor (CNI) (n=32). The remaining patients were maintained on either steroids and a CNI (n=3) or steroids and mycophenolate mofetil (n=2). Induction therapy with either basiliximab (Simulect, Novartis, n=26), anti-thymocyte globulin (Thymoglobulin, Genzyme, n=3) or alemtuzumab (Campath-1H, ILEX, n=2) was used at the discretion of the surgeon. Tacrolimus (Prograf, Fujisawa) was utilized in nearly all cases (n=34), with cyclosporine (Neoral, Novartis) given in only one patient. Steroids were tapered during the transplant hospitalization to prednisone 30 mg/day. This dose was further tapered over the first postoperative months to a baseline of 5–10 mg/day. Presently, SLK recipients receive basiliximab induction and are maintained on mycophenolic acid, tacrolimus, and low-dose prednisone post-operatively.
The primary endpoints in this study were patient and graft survival. MELD score was calculated for all patients including those in the pre-MELD era based on total bilirubin, INR and creatinine. Glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease (MDRD) equation.(15
) Unexplained elevations in liver function tests were initially evaluated with duplex ultrasonography of the liver allograft to assess vascular patency. If hepatic vascular flow was normal, percutaneous liver biopsy was performed and evaluated using hematoxylin and eosin staining. Renal biopsies were performed in patients with a creatinine elevated at least 20% above baseline, and were evaluated using hematoxylin and eosin staining per the Banff Criteria. Delayed kidney allograft function was defined as requiring hemodialysis within the first 7 days of transplantation. Mean follow-up in DCD recipients was 1.8±2.2 years, as compared to 3.5±2.6 years in DBD recipients.
Statistical analysis was performed with SAS software. Data are presented as median values with ranges. Rates of rejection, rates of biliary complications, and patient and graft survival rates were estimated using Kaplan-Meier analysis. Group comparisons were performed using a log-rank test. Continuous variables were compared using the Wilcoxon rank sum test and discrete variables were compared using the Fisher’s exact test. P-values < 0.05 were considered significant.
DCD procurement technique
Our DCD organ recovery technique has been previously described. (16
) To minimize warm ischemic time we routinely obtain additional informed consent for the placement of femoral arterial and venous cannulas under local anesthesia. After declaration of death we begin flushing through the femoral arterial cannula with University of Wisconsin solution and begin venous venting through the venous cannula. We then proceed with rapid opening of the abdomen and chest. The supraceliac aorta is cross clamped and the IVC is vented in the chest. All organs are removed en bloc to the back table where the portal vein is flushed with additional UW solution and the common bile duct is irrigated until clear. The organs are transported back to the University of Wisconsin and separated in cold preservative solution on the back table.
Simultaneous liver-kidney transplantation technique
The liver transplant during SLK transplantation is performed using standard piggyback techniques with vena caval anastomosis to the common orifices of the three hepatic veins. As we have gained experience with SLK transplantation using DCD donors, we have modified our technique slightly. After the vena caval and portal venous anastomoses are completed, the liver is flushed with 1L lactated Ringer’s with 2 ampules of 25% albumin to eliminate the residual UW preservation solution. The donor liver is then reperfused through the portal vein. To decrease the incidence of severe post reperfusion syndrome, we now perform an additional 300 cc blood flush of the liver through the infrahepatic IVC. The clamp of the suprahepatic IVC just below the anastomosis is released, restoring the liver outflow, and the infrahepatic IVC is ligated. The hepatic artery anastomosis is then completed.
A meticulous search for hemostasis and surgical bleeding is performed. The perihepatic dissection areas are packed and the subcostal incision is closed with towel clamps. The renal transplant is then performed via a separate right lower quadrant incision using the iliac vessels and standard techniques. After revascularization of the kidney and the completion of the neoureterocystostomy, attention is returned to the liver transplant. Once hemostasis is satisfactory, the biliary anastomosis is performed, typically with an end-to-end choledochocholedochostomy. All anastomoses are again inspected and both wounds are closed once adequate hemostasis is obtained. By using this procedural sequence, we are able to evacuate any perihepatic hematomas that have developed during the kidney transplant without having to reopen the liver transplant incision. Both transplants are typically performed by the same team.