Nefrología 2018-01-24 | doi: 10.1016/j.nefro.2017.11.014

Triple functioning renal allograft after repeated liver–kidney transplantation due to liver failure


a Nuclear Medicine Department, Hospital Clinic, Barcelona, Spain
b Nephrology and Renal Transplant Department, Hospital Clinic, Barcelona, Spain

A 56-year-old woman who underwent 10 years earlier simultaneous liver–kidney transplantation due to polycystic disease (Fig. 1A) showed progressive transaminase elevation secondary to hepatotoxicity due to venlafaxine. The patient was diagnosed of liver rejection and retransplant was required. However, the patient also presented progressive renal failure worsened by liver failure (Cr 4.5mg/dL), so a second simultaneous liver–kidney transplant was performed to prevent subsequent dialysis. Fifteen days later showed a prominent liver graft dysfunction and again was candidate for a new liver transplant. At this point, the second kidney graft was dysfunctional and considered as acute tubular necrosis by ultrasound. A third simultaneous liver–kidney transplant was considered and finally performed without remarkable incidences (Fig. 1B). Renogram has been widely used in the follow-up of renal transplant function and has proved reliable to define the integrity of the kidney. The current case shows functional recovery of all three transplanted kidneys demonstrated by the renogram images (Fig. 1C) and the correspondent generated curves for each renal transplant (Fig. 2). To our knowledge, this is a rare case not previously reported which raises the question about the need of systematic kidney transplantation when a liver transplant is required.1,2

Fig. 1.

Baseline CT coronal views show policystic kidneys before the first liver–kidney trasnsplantation (A). Follow-up CT locates the three transplanted kidneys in both sides of the pelvis (B). A renogram study using 99mTc-MAG3 was performed identifying different degrees of radiotracer uptake in all three transplanted kidneys (C).

Fig. 2.

99mTc-MAG3 renogram curves were generated after drawing whole-kidney and background regions of interest for each renal transplant. The results obtained were expressed as the maximum count ratios: 200 cps (A), 117 cps (B) and 1640 cps (C), respectively. The relative differential function showed the following distribution of 16% for the right medial graft (A), 9% for the left graft (B) and 75% for the right lateral graft (C).

Referencias bibliográficas
1.
C.M. Aparici,S.N. Bains,D. Carlson,J. Qian,D. Liou,D. Wojciechowki
Recovery of native renal function in patients with hepatorenal syndrome following combined liver and kidney transplant with mercaptoacetyltriglycine-3 renogram: developing a methodology
.World J Nucl Med, 15 (2016), pp. 44-49 http://dx.doi.org/10.4103/1450-1147.172140
2.
M.R. Palmer,K.J. Donohoe,J.M.A. Francis,D. Mandelbrot
Evaluation of relative renal function for patients who had undergone simultaneous liver–kidney transplants using Tc-99m-MAG3 scintigraphy with attenuation correction from anatomical images and SPECT/CT
.Nucl Med Commun, 32 (2011), pp. 738-744 http://dx.doi.org/10.1097/MNM.0b013e328347e958
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