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    "textoCompleto" => "NEFROLOGÍA. Vol. XXII. Suplemento 5. 2002 Combined liver and kidney transplantation L. Bäckman, MD, PhD Department of Transplantation and Liver Surgery. Sahlgenska University Hospital. Sweden INTRODUCTION Liver failure, acute or chronic is commonly associated with some degree of renal dysfunction. In selected patients with an irreversible renal failure a combined kidney and liver transplantation may therefore be indicated. Hepatorenal syndrome is a controversial diagnosis that most commonly reverses after liver transplantation (Ltx). The diagnosis of hepatorenal syndrome is made after the exclusion of a coexisting renal disease. The evaluation of a liver transplant recipient with renal failure should include urinalysis, estimation of the glomerular filtration rate (GFR), and quantification of proteinuria, blood urea nitrogen measurement, creatinine measurement, ultrasound of the kidneys and preferrably also a kidney biopsy. 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The same is also true with creatinine clearence estimates RESULTS AND DISCUSSION There are a limited number of reports and the number of patients is relatively small 2-8. Therefore it is difficult to make conclusions and recommendations based on these reports. Several papers also include combined liver and kidney transplants preformed over longer periods of time 2, 3. Patient selection is, as always an important factor when analyzing the outcome. An obvious indication for a combined kidney and liver transpantation is polycystic liver and kidney disease. The need for kidney transplantation in those patients in need for Ltx was however reported to be low, 1/14 4. From a surgical - technical point a combined liver and kidney transplantation is usually not more complicated than a Ltx, however the procedure is of course more time consuming than a regular Ltx. The liver is transplanted first followed by the kidney from the same donor. The risk of intraoperative and post operative bleeding must be considered and the risk of acute tubular necrosis post-transplant. This risk should theoretically not be higher than after any kidney transplantation but some sort of kidney assisting device i.e., contious venous-venous hemofiltration should be used during the Ltx in order to optimize the fluid and electrolyte balance i.e, potassium and circulatory status. Post-transplant a nonnephrotoxic immunosuppressive regimen, or a regimen with low nephrotoxic potential should preferrably be used 9. The survival rates seem to be comparable with patients undergoing Ltx. It was however recommended that the indication for simultaneous organ transplantation should be considered earlier than for transplantation involving only one organ 5. In a pediatric study the 5 year survival rates after combined kidney and liver transplantation were comparable to patients undergoing Ltx alone (67% versus 69%, respectively) 3. The most striking result is the relatively low number of kidney rejection episodes after combined liver and kidney transplantation. The incidence of acute rejection was reported to be 30% for the liver and 15% for the kidney, respectively 5. It was therefore suggested that the liver immunologically protected the kidney from being rejected 2, 6. It was also reported on successful kidney transplants in patients against a positive cross match and multispecific HLA antibodies after a combined liver and kidey transplantation 6, 10. In a follow-up on 18 patients undergoing combined liver and kidney transplantation 8 had lymphocytotoxic antibodies and 5 had positive cross-matches pre-transplant. The 1-year patient survival was excellent (95%) and the long-term survi67 L. BÄCKMAN val was not impaired in patients with a positive cross-match 6. The exact mechanism behind this effect is unknown. It was suggested that the liver graft neutralized or inactivated the multispecific antibodies 10. When the cross-match was repeated during the Ltx the cross-match became negative after portal reperfusion. In a case report from our center the long-term kidney and liver function was excellent in a sensitized patient undergoing a combined liver and kidney transplantation 10. This patient, a 50 year old woman with chronic glomerulonephritis received her 4th kidney transplant in combination with a livergraft from the same donor against a positive cross-match. The indication for Ltx was end stage liver disease secondary to chronic hepatitis C. Her current immunosuppression consits of Prograf (1 mg bid) and CellCept (250 mg qd) and off steroids completely, with a GFR of 35 ml/min and a creatinine level of 125. She is also back to full time work. In conclusion, combined liver and kidney transplantation is the treatment of choice in patients with end-stage liver disease and irreversible renal failure. The results are similar to isolated liver transplantation but the number of acute rejection episodes in the kidney seems to be less. A kidney transplantation may be performed against a positive cross-match in sensitized patient when done after a liver transplantation from the same donor. The liver seems to imunologically protect the transplanted kidney by unknown mechanisms. REFERENCES 1. Bäckman L, Olausson M, Mjörnstedt L, Herlenius G, Friman S: Renal Function after Liver Transplantation. Transplant Proc 2001 (in press). 2. Margreiter R, Streurer W, Spechtenhauser B, Konigsranier A. Kidney transplantation together with another solid organ from the same donor- a singel center progress report. Clin Nephrol 53: 38-433, 2000. 3. Grewal HP, Brady L, Cronin DC, Loss GE, Siegel CT, Oswald K, Fisher JS, Bruce DC, Aronsson AJ, Woodle ES, Millis JM, Thistletwaite JR, Newell KA: Combined liver and kidney transplantation in children. Transplantation 15: 70, 2000. 4. Pirenne J, Aerts R, Yoong K, Gunson B, Koshiba T, Fourneau I, Mayer D, Buckels J, Mirza D, Roskams T, Elías E, Nevens F, Fevery J, McMaster P: Liver transplantation for polycystic liver disease. Liver Transpl 7: 238-245, 2001. 5. Kleim V, Ringe B, Frei U, Pichlmayr R: Single-center experience of combined liver and kidney transplantation. Clin Transplant 9: 39-44, 1995. 6. Lang M, Kahl A, Bechstein W, Neumann U, Knoop M, Frei U, Neuhaus P: Combined liver-kidney transplantation: long-term follow up in 18 patients. Transplant Int 11: 155-159, 1998. 7. Hiesse C, Samuel D, Bensadoun H, Blanchet P, Castaing D, Adam R, Chraibi A, Charpentier B, Bismuth H: Combined liver and kidney transplantation in patients with chronic nephritis associated with end-stage liver disease. Nephrol Dial Transplant 6: 129-133, 1995. 8. Jeyarajaah DR, Gonwa TA, McBride M, Testa G, Abbasolglu O, Husberg BS, Levy MF, Goldstein RM, Klintmalm GB: Hepatorenal syndrome: combined liver kidney transplants versus isolated liver transplants. Transplantation 64: 1760-1765, 1997. 9. Bäckman L, Morales JM: Is non-nephrotoxic immunosupression a possibility. Transplantation 69: 27-30, 2000. 10. Mjörnstedt L, Friman S, Bäckman L, Rydberg L, Olausson M: Combined liver and kidney transplantation against a positive cross match in a patient with multispecific HLA-antibodies. Transplant Proc 29: 3164-3165, 1997. 68 "
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    "textoCompleto" => "NEFROLOGÍA. Vol. XXII. Suplemento 5. 2002 Combined liver and kidney transplantation L. Bäckman, MD, PhD Department of Transplantation and Liver Surgery. Sahlgenska University Hospital. Sweden INTRODUCTION Liver failure, acute or chronic is commonly associated with some degree of renal dysfunction. In selected patients with an irreversible renal failure a combined kidney and liver transplantation may therefore be indicated. Hepatorenal syndrome is a controversial diagnosis that most commonly reverses after liver transplantation (Ltx). The diagnosis of hepatorenal syndrome is made after the exclusion of a coexisting renal disease. The evaluation of a liver transplant recipient with renal failure should include urinalysis, estimation of the glomerular filtration rate (GFR), and quantification of proteinuria, blood urea nitrogen measurement, creatinine measurement, ultrasound of the kidneys and preferrably also a kidney biopsy. 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Pirenne J, Aerts R, Yoong K, Gunson B, Koshiba T, Fourneau I, Mayer D, Buckels J, Mirza D, Roskams T, Elías E, Nevens F, Fevery J, McMaster P: Liver transplantation for polycystic liver disease. Liver Transpl 7: 238-245, 2001. 5. Kleim V, Ringe B, Frei U, Pichlmayr R: Single-center experience of combined liver and kidney transplantation. Clin Transplant 9: 39-44, 1995. 6. Lang M, Kahl A, Bechstein W, Neumann U, Knoop M, Frei U, Neuhaus P: Combined liver-kidney transplantation: long-term follow up in 18 patients. Transplant Int 11: 155-159, 1998. 7. Hiesse C, Samuel D, Bensadoun H, Blanchet P, Castaing D, Adam R, Chraibi A, Charpentier B, Bismuth H: Combined liver and kidney transplantation in patients with chronic nephritis associated with end-stage liver disease. Nephrol Dial Transplant 6: 129-133, 1995. 8. 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2023 Diciembre 18 24 42
2023 Noviembre 28 26 54
2023 Octubre 45 42 87
2023 Septiembre 48 23 71
2023 Agosto 44 34 78
2023 Julio 32 53 85
2023 Junio 31 36 67
2023 Mayo 29 45 74
2023 Abril 31 20 51
2023 Marzo 22 21 43
2023 Febrero 22 26 48
2023 Enero 26 24 50
2022 Diciembre 34 38 72
2022 Noviembre 23 27 50
2022 Octubre 41 43 84
2022 Septiembre 44 35 79
2022 Agosto 31 37 68
2022 Julio 36 48 84
2022 Junio 38 34 72
2022 Mayo 37 25 62
2022 Abril 47 44 91
2022 Marzo 45 43 88
2022 Febrero 38 32 70
2022 Enero 39 39 78
2021 Diciembre 28 37 65
2021 Noviembre 31 38 69
2021 Octubre 32 40 72
2021 Septiembre 23 39 62
2021 Agosto 32 27 59
2021 Julio 17 33 50
2021 Junio 21 39 60
2021 Mayo 31 36 67
2021 Abril 42 29 71
2021 Marzo 34 33 67
2021 Febrero 36 28 64
2021 Enero 34 20 54
2020 Diciembre 21 11 32
2020 Noviembre 24 17 41
2020 Octubre 16 14 30
2020 Septiembre 26 19 45
2020 Agosto 17 4 21
2020 Julio 35 8 43
2020 Junio 16 6 22
2020 Mayo 32 9 41
2020 Abril 35 12 47
2020 Marzo 25 15 40
2020 Febrero 45 13 58
2020 Enero 38 15 53
2019 Diciembre 20 15 35
2019 Noviembre 8 4 12
2019 Octubre 7 5 12
2019 Septiembre 16 12 28
2019 Agosto 11 11 22
2019 Julio 18 11 29
2019 Junio 10 18 28
2019 Mayo 4 9 13
2019 Abril 34 35 69
2019 Marzo 8 11 19
2019 Febrero 8 8 16
2019 Enero 7 9 16
2018 Diciembre 31 19 50
2018 Noviembre 43 14 57
2018 Octubre 45 5 50
2018 Septiembre 29 10 39
2018 Agosto 18 7 25
2018 Julio 18 10 28
2018 Junio 17 10 27
2018 Mayo 19 5 24
2018 Abril 21 5 26
2018 Marzo 16 6 22
2018 Febrero 13 4 17
2018 Enero 16 6 22
2017 Diciembre 18 4 22
2017 Noviembre 12 5 17
2017 Octubre 19 4 23
2017 Septiembre 12 3 15
2017 Agosto 11 2 13
2017 Julio 18 10 28
2017 Junio 13 10 23
2017 Mayo 20 17 37
2017 Abril 12 7 19
2017 Marzo 14 6 20
2017 Febrero 15 3 18
2017 Enero 32 5 37
2016 Diciembre 42 4 46
2016 Noviembre 40 10 50
2016 Octubre 58 3 61
2016 Septiembre 91 3 94
2016 Agosto 116 0 116
2016 Julio 133 10 143
2016 Junio 88 0 88
2016 Mayo 80 0 80
2016 Abril 55 0 55
2016 Marzo 47 0 47
2016 Febrero 60 0 60
2016 Enero 49 0 49
2015 Diciembre 41 0 41
2015 Noviembre 44 0 44
2015 Octubre 41 0 41
2015 Septiembre 32 0 32
2015 Agosto 35 0 35
2015 Julio 33 0 33
2015 Junio 6 0 6
2015 Mayo 21 0 21
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