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Outcome of Renal Transplantation Subsequent to Liver, Heart, or Lung Transplantation
Outcome of Renal Transplantation Subsequent to Liver, Heart, or Lung Transplantation H. Tarnow, G. Herlenius, S. Friman, M. Olausson, G. Nordén, M. Felldin, and L. Bäckman ABSTRACT Renal dysfunction is a growing problem after liver, heart, or lung transplantation with the subsequent need for dialysis or renal transplantation. The aim of this study was to analyze the outcome after a subsequent kidney transplantation (secondary kidney transplantation) in liver, heart, or lung transplantation recipients. All secondary kidney transplantation patients from 1985 to 2006 were identified for the cause of kidney failure, time after initial transplantation, and current kidney function. One thousand two hundred three patient charts were reviewed including 22 (1.8%) secondary kidney transplantations: eight after lung, eight after heart, and six after liver transplantation. Renal failure was the result of perioperative renal failure (n ⫽ 3), toxic effects of cyclosporine (n ⫽ 16), a combination of cyclosporine nephrotoxicity and vascular ischemia (n ⫽ 3), or chronic renal failure due to polycystic kidney disease (n ⫽ 1). The median time after the initial organ transplantation was 114 months (range 30 to 241 months). The most recent median creatinine value was 103 mol/L (82 to 704 mol/L). Renal transplant rejection was noted in five patients: four in the lung transplant group, and one after heart transplantation. Three patients were deceased, one from secondary renal failure. One renal allograft was removed after renal artery thrombosis. In conclusion, there is sometimes a need for subsequent kidney transplantation after liver, heart, or lung transplantation. The outcome of renal transplantation subsequent to liver, heart, or lung transplantation is good with satisfactory renal function in this study population.
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ECIPIENTS OF NONRENAL organ transplants are at risk of developing renal failure. Acute renal failure is a common complication, requiring dialysis in 8% of patients.1 Chronic renal dysfunction of some degree has been reported in 10% to 80% of transplanted patients, whereas end-stage renal disease requiring chronic dialysis has been reported in up to 20% of nonrenal transplant recipients.2 In a study of 69,321 nonrenal organ transplantation patients in the United State, 3297 (4.8%) required dialysis or renal transplantation after a median follow-up of 36 months.3 The present study was performed to analyze the nonrenal organ transplantation patients receiving a secondary kidney transplantation at a single center. PATIENTS AND METHODS All liver, heart, and lung transplant recipients from 1985 to 2006 were analyzed (n ⫽ 1203), to identify all patients who had a subsequent kidney transplantation. We analyzed age, diagnosis, time of nonrenal organ transplant, type of organ, time to renal
transplantation, and cause of kidney failure. We also recorded the immunosuppressive regimen, most current creatinine level, glomerular filtration rate, and outcome of renal transplantation (ie, patient and graft survival as well as incidence of rejection).
RESULTS
Among 1203 reviewed cases, 1.8% or 22 patients needed a secondary kidney transplantation: eight following lung, eight following heart, and six after liver transplantation. The median age was 50 years (range 22 to 66 years). Renal failure was a result of perioperative renal failure (n ⫽ 3), toxic effects of cyclosporine (n ⫽ 16), a combination of cyclosporine nephrotoxicity and vascular ischemia (n ⫽ 2), or chronic renal failure due to polycystic kidney disease From the Department of Transplantation and Liver Surgery, Sahlgrenska University Hospital, Göteborg, Sweden. Address reprint requests to L. Bäckman, Dept of Transplantation and Liver Surgery, Sahlgrenska University Hospital, SE41345 Göteborg, Sweden. E-mail: [email protected]
© 2006 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/06/$–see front matter doi:10.1016/j.transproceed.2006.07.045
Transplantation Proceedings, 38, 2649 –2650 (2006)
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TARNOW, HERLENIUS, FRIMAN ET AL
Fig 1. Renal failure in heart, lung, or liver transplant patients was a result of perioperative renal failure (n ⫽ 3), toxic effects of cyclosporine (n ⫽ 16), a combination of cyclosporine effects and vascular ischemia (n ⫽ 2), or chronic renal failure due to polycystic kidney disease (n ⫽ 1).
(n ⫽ 1; Fig 1). The median time after the initial organ transplantation was 114 months (range 30 to 241 months). The most recent serum creatinine value was 103 mol/L (median, range 82 to 704 mol/L). The median post–renal transplant glomerular filtration rate was 34 mL/min (9 to 78 mL/min; n ⫽ 17). Renal transplant rejection was noted in five patients: four in the lung transplant group, and one after heart transplantation. Three patients were deceased, one from secondary renal failure. One renal transplant was removed after arterial thrombosis. DISCUSSION
Patients with a nonrenal organ transplant have an increased risk to develop chronic renal failure, which is associated with a more than fourfold increased risk of death.3 Risk factors are hypertension, diabetes mellitus, hepatitis C infection, postoperative acute renal failure, pretransplant disease, and immunosuppressive medications. The risk of chronic renal failure after liver transplantation has been reported to be higher among patients treated with cyclosporine than among those treated with tacrolimus.3 Chronic renal failure eventually leads to end-stage renal disease, which is treated by dialysis or kidney transplantation. The 5-year risk of death has been reported to be significantly lower after kidney transplantation as compared with dialysis.3 In our patients 1.8% of nonrenal organ transplant patients received a secondary kidney transplant at a median
time of 10 years after the first, nonrenal allograft. There were relatively more secondary kidney transplants following heart or lung transplantation than following liver transplantation (2.2%, 2.8%, and 0.7%, respectively). Interestingly, all renal rejection episodes were seen in heart and/or lung transplant patients, and none among the patients that were liver transplants. In the majority (73%) of patients the reason for kidney failure and transplantation was chronic cyclosporine nephrotoxicity. The use of newer immunosuppressive drugs and regimens (ie, tacrolimus) may reduce this risk in the future. In conclusion, the outcome of renal transplantation subsequent to liver, heart, or lung transplantation was good with satisfactory renal function in this study population. Patient and graft survivals were good, and the incidence of renal allograft rejection was low. Attention to side effects of immunosuppressive drugs and pretransplant disease may reduce the need for secondary kidney transplantations. REFERENCES 1. Wyatt CM, Arons RR: The burden of acute renal failure in nonrenal solid organ transplantation. Transplantation 78:1351, 2004 2. Stratta P, Canavese C, Quaglia M, et al: Posttransplantation chronic renal damage in nonrenal transplant recipients. Kidney Int 68:1453, 2005 3. Ojo AO, Held PJ, Port FK, et al: Chronic renal failure after transplantation of a nonrenal organ. N Engl J Med 349:931, 2003
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ECIPIENTS OF NONRENAL organ transplants are at risk of developing renal failure. Acute renal failure is a common complication, requiring dialysis in 8% of patients.1 Chronic renal dysfunction of some degree has been reported in 10% to 80% of transplanted patients, whereas end-stage renal disease requiring chronic dialysis has been reported in up to 20% of nonrenal transplant recipients.2 In a study of 69,321 nonrenal organ transplantation patients in the United State, 3297 (4.8%) required dialysis or renal transplantation after a median follow-up of 36 months.3 The present study was performed to analyze the nonrenal organ transplantation patients receiving a secondary kidney transplantation at a single center. PATIENTS AND METHODS All liver, heart, and lung transplant recipients from 1985 to 2006 were analyzed (n ⫽ 1203), to identify all patients who had a subsequent kidney transplantation. We analyzed age, diagnosis, time of nonrenal organ transplant, type of organ, time to renal
transplantation, and cause of kidney failure. We also recorded the immunosuppressive regimen, most current creatinine level, glomerular filtration rate, and outcome of renal transplantation (ie, patient and graft survival as well as incidence of rejection).
RESULTS
Among 1203 reviewed cases, 1.8% or 22 patients needed a secondary kidney transplantation: eight following lung, eight following heart, and six after liver transplantation. The median age was 50 years (range 22 to 66 years). Renal failure was a result of perioperative renal failure (n ⫽ 3), toxic effects of cyclosporine (n ⫽ 16), a combination of cyclosporine nephrotoxicity and vascular ischemia (n ⫽ 2), or chronic renal failure due to polycystic kidney disease From the Department of Transplantation and Liver Surgery, Sahlgrenska University Hospital, Göteborg, Sweden. Address reprint requests to L. Bäckman, Dept of Transplantation and Liver Surgery, Sahlgrenska University Hospital, SE41345 Göteborg, Sweden. E-mail: [email protected]
© 2006 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/06/$–see front matter doi:10.1016/j.transproceed.2006.07.045
Transplantation Proceedings, 38, 2649 –2650 (2006)
2649
2650
TARNOW, HERLENIUS, FRIMAN ET AL
Fig 1. Renal failure in heart, lung, or liver transplant patients was a result of perioperative renal failure (n ⫽ 3), toxic effects of cyclosporine (n ⫽ 16), a combination of cyclosporine effects and vascular ischemia (n ⫽ 2), or chronic renal failure due to polycystic kidney disease (n ⫽ 1).
(n ⫽ 1; Fig 1). The median time after the initial organ transplantation was 114 months (range 30 to 241 months). The most recent serum creatinine value was 103 mol/L (median, range 82 to 704 mol/L). The median post–renal transplant glomerular filtration rate was 34 mL/min (9 to 78 mL/min; n ⫽ 17). Renal transplant rejection was noted in five patients: four in the lung transplant group, and one after heart transplantation. Three patients were deceased, one from secondary renal failure. One renal transplant was removed after arterial thrombosis. DISCUSSION
Patients with a nonrenal organ transplant have an increased risk to develop chronic renal failure, which is associated with a more than fourfold increased risk of death.3 Risk factors are hypertension, diabetes mellitus, hepatitis C infection, postoperative acute renal failure, pretransplant disease, and immunosuppressive medications. The risk of chronic renal failure after liver transplantation has been reported to be higher among patients treated with cyclosporine than among those treated with tacrolimus.3 Chronic renal failure eventually leads to end-stage renal disease, which is treated by dialysis or kidney transplantation. The 5-year risk of death has been reported to be significantly lower after kidney transplantation as compared with dialysis.3 In our patients 1.8% of nonrenal organ transplant patients received a secondary kidney transplant at a median
time of 10 years after the first, nonrenal allograft. There were relatively more secondary kidney transplants following heart or lung transplantation than following liver transplantation (2.2%, 2.8%, and 0.7%, respectively). Interestingly, all renal rejection episodes were seen in heart and/or lung transplant patients, and none among the patients that were liver transplants. In the majority (73%) of patients the reason for kidney failure and transplantation was chronic cyclosporine nephrotoxicity. The use of newer immunosuppressive drugs and regimens (ie, tacrolimus) may reduce this risk in the future. In conclusion, the outcome of renal transplantation subsequent to liver, heart, or lung transplantation was good with satisfactory renal function in this study population. Patient and graft survivals were good, and the incidence of renal allograft rejection was low. Attention to side effects of immunosuppressive drugs and pretransplant disease may reduce the need for secondary kidney transplantations. REFERENCES 1. Wyatt CM, Arons RR: The burden of acute renal failure in nonrenal solid organ transplantation. Transplantation 78:1351, 2004 2. Stratta P, Canavese C, Quaglia M, et al: Posttransplantation chronic renal damage in nonrenal transplant recipients. Kidney Int 68:1453, 2005 3. Ojo AO, Held PJ, Port FK, et al: Chronic renal failure after transplantation of a nonrenal organ. N Engl J Med 349:931, 2003