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Combined liver–kidney transplantation
indian journal of transplantation 9 (2015) 47–60
Background: Organ donation system in Iran is based on transfer of brain dead donors to organ procurement units (OPU) of university hospitals for management. It has been previously shown that transfer of critically ill patients can be associated with a decrease in oxygenation capacity of lungs as well as hemodynamic casualties. Aims: In this study we examined the impact of transfer process on donor's lungs quality indices such as PaO2/FIO2 ratio and effect of a single recruitment maneuver on its reversal. Methodology: In this two-phase controlled study we followed 52 brain dead donors during transfer and carefully followed the oxygenation criteria of their lungs. We also extracted 23 matched brain dead donor's information retrospectively to form a historical control group. Three blood samples for arterial blood gases were collected immediately before and after transfer (T1 and T2) and 2 hours after an alveolar recruitment maneuver. (T3) We also obtained arterial blood gas test results from records with the same time interval in control group. Pvalue <0.05 was considered significant. Lung suitability criteria in blood gas sample for donation was a P/F ratio higher than 300. Results: There were no differences in age, cause of brain death, intubation days, presence of chest trauma, chest tube and the amount of fluid administered during transfer in case and control groups. (Table.1) PaO2/FIO2 at T1 and T2 also were not statistically different in both groups. PaO2/FIO2 dropped significantly after transfer (from 302.1 119.4 to 259 115.8 mmHg, p < 0.001) the transfer process turned 8 potential lung donors to inappropriate ones (4 in each group) which formed 17.4% of all donors. The only influencing factor was the amount of IV-fluid administered during transfer period with a positive correlation with PaO2/FIO2 drop (p = 0.02 and correlation coefficient = 0.540) The PaO2/FIO2 decrease from T1 to T3 was significantly lower in the recruitment maneuver group than in control group ( 4.3 44.1 vs 69.5 61.4 mmHg, p < 0.001). Conclusions: Transfer of brain dead donors from original hospitals to OPUs is associated with a decrease in PaO2/FIO2 and as a result the percentage of potential lung donors. This can be significantly reversed by a single alveolar recruitment maneuver immediately after hemodynamic stabilization. http://dx.doi.org/10.1016/j.ijt.2015.09.032 Abstract #: ISOT2015-52 Tissue matching index – A quantitative score for donor selection in organ transplantation Sonai Muthu, Sujata Mitra Tata Main Hospital, Jamshedpur 831001, India Background: Matching the two HLA antigens of class I and class II present in each locus has different significance in different organ transplantation. It is unanimously accepted that HLA identical (0MM) living related or cadaver grafts show a better survival than partially mismatched grafts. Matching hierarchy for renal transplantation is in the order of DR > B > A. Conventionally the donor in selected by counting the MisMatch (MM) scores. This MM scoring method has many disadvantages. Aims: This study has been done to develop a method to quantify the degree of HLA matching for renal transplantation in three loci comparison, and to apply in four, five and six loci comparisons. Methodology: A numerical method analogous to the positional number system has been developed to quantify the degree of HLA match between the recipient and the donor. Two terms, namely Tissue Matching Score (TMS) and Tissue Matching
59
Index (TMI) have been introduced and defined. TMS has been defined as the sum of locus weighted score assigned to each antigen match, when comparing the HLA of the recipient with that of the donor. Tissue Matching Index is defined as the ratio between the TMS obtained when comparing the HLA of the recipient with that of the donor and the value of TMS obtained in the best possible HLA match. For convenience, the value of Tissue Matching Index was expressed as percentage TMI by multiplying this ratio by hundred. The donor having the maximum value of TMI was considered as the best match. Results: In three loci (DR, B and A in renal transplantation) comparison, 27 possible scores of percent TMI are observed between 0 and 1. Each value of TMI is unique for every possible combination in the matching loci. In an ideal match, when all the antigens compared are exactly the same for the recipient and the donor, the value of TMI becomes one. This is equivalent to the conventional qualitative score of zero MisMatch (0 MM). In the worst match, where none of the donor Ts antigen matches with that of the recipient, the value of TMI becomes zero. This is equivalent to the conventional qualitative score of six MisMatch (6 MM). The MisMatch scores of 0 MM, 1 MM, 2 MM, 3 MM, 4 MM, 5 MM and 6 MM have 1,3,6,7,6,3 and 1 different values of percent TMI score respectively Maximum overlap of MM score is seen in 3MM score that could be donor could mean any one of the 7 possible combinations of TMI scores. There are 81, 243 and 729 discrete TMI scores observed in 4, 5 and 6 loci comparisons. Conclusions: Tissue Matching Index is useful in selecting the donor with scientifically acceptable degree of HLA match. It overcomes all the problems that are found in the conventional MM scoring method. This parameter can be easily used in combination with the other factors by the organ sharing networks. http://dx.doi.org/10.1016/j.ijt.2015.09.033 Abstract #: ISOT2015-88 Combined liver–kidney transplantation Prakash V. Chauhan, Pranjal R. Modi Institute of Kidney Diseases and Research Centre, Dr. HL Trivedi Institute of Transplantation Sciences, Ahmedabad, India Background: Liver transplantation has entered an era with increased survival. The renal morbidities are also becoming more common at long time. In both adult and paediatric group of patients chronic renal failure and end stage renal disease is a major factor that affects long term quality of life and hinders survival. The median waiting time for liver transplant recipients is now influenced by MELD scores. Potential recipients of liver transplant are subjected to develop clinically apparent nephropathy. Aims: To define various indications of transplant of liver and kidney at the same surgery. To discuss our centre experience of combined liver and kidney transplant. Methodology: Patients with liver and kidney dysfunction where operated for combined liver–kidney transplant. Two patients having primary oxalosis with renal dysfunction and other having cirrhosis with hepatorenal syndrome. Preoperative and postoperative renal and liver function parameters compared and analyzed. Results: Two Patients of primary oxalosis did well in postoperative phase. Liver enzymes settled down in 5 days. Serum creatinine came down from 3.98 mg/dl preoperative level to 0.53 mg/dl after surgery. Abdomen was kept opened due to severe oedematous abdominal organs in OT for 3 days. She was on CRRT for 4 days. Until renal function recovered. Subsequently abdomen wound closure done and patient
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indian journal of transplantation 9 (2015) 47–60
discharged on 18th post-operative day. Another patient of cirrhosis with hepatorenal syndrome who underwent CLKT also maintained on CRRT during perioperative period after which his kidney function recovered and serum creatinine came down from 5 mg/dl of preoperative level to 1 mg/dl postoperatively. Liver enzymes also came to normal limits within one week. Conclusions: CLKT for hepatorenal syndrome is indicated in patients receiving haemodialysis for longer than 8 weeks and primary oxalosis confers advantages in patient survival. In CLKT liver is immunoprotective for the kidney as evidenced by less no of renal allograft rejection compared to renal transplant. http://dx.doi.org/10.1016/j.ijt.2015.09.034 Clinical spectrum of tuberculosis in renal transplant recipients S. Murugananth, R. Arul, T. Dineshkumar, J. Dhanapriya, R. T. Sakthirajan, N. Gopalakrishnan Madras Medical College, Chennai & Coimbatore Medical College, Coimbatore, India Aim: To assess the prevalence, risk factors and clinical profile of tuberculosis in renal transplant recipients. Material and methods: Patients who underwent renal transplantation at Rajiv Gandhi Govt. General Hospital from 2007 to 2014 were evaluated retrospectively. Patients with tuberculosis defined by demonstration of AFB in BAL/Sputum/Culture, body serous fluids analysis suggestive of tuberculosis, histopathological evidence of TB by FNAC/Excision biopsy and favourable response to anti TB drugs in those who had inconclusive evidence were included in the study. Those patients
who had proven tuberculosis in pre-transplant and continuing ATT in post transplant were excluded. Results: A total of 477 renal transplant patients were studied retrospectively, out of which 46 patients had tuberculosis. Of them 42 (91%) were males. 39 (84%) patients received kidneys from live related donors. Most patients received triple immunosuppression. Mean duration between transplantation and detection of tuberculosis was 23 months [range (1 month–10 yrs)]. About 66% (29/36) patients had pulmonary tuberculosis and 21% had pleural tuberculosis. Disseminated TB was diagnosed in 2 (4%) and TB lymphadenitis was found in 3 (6%) patients. TB pericarditis and TB meningitis were found in 1 patient each. 19% of patients had associated fungal infection and 19% had Hepatitis C virus infection. Cytomegalovirus (CMV) was found in 13%. Co-existing new onset diabetes after transplantation (NODAT) was found in 22%. In patients who had TB, 22% of them had previous history of antirejection therapy. 5% had past history of ATT and 5% had family history of TB. 60% of patients with pulmonary tuberculosis had positive yield by means of Sputum/BAL/culture. 4 patients died due to reasons directly attributed to TB (8%). 2 patients died to associated fungal infections. ATT induced hepatitis was found in 2 patients and optic neuritis in one patient. Conclusion: Prevalence of TB in our renal transplant recipients is 10%. Most of the patients developed tuberculosis more than 1 year after transplantation. Pulmonary tuberculosis was the most common form. NODAT, CMV, hepatitis C, fungal infections and antirejection therapy were found to be risk factors for post transplant tuberculosis. http://dx.doi.org/10.1016/j.ijt.2015.09.035
Background: Organ donation system in Iran is based on transfer of brain dead donors to organ procurement units (OPU) of university hospitals for management. It has been previously shown that transfer of critically ill patients can be associated with a decrease in oxygenation capacity of lungs as well as hemodynamic casualties. Aims: In this study we examined the impact of transfer process on donor's lungs quality indices such as PaO2/FIO2 ratio and effect of a single recruitment maneuver on its reversal. Methodology: In this two-phase controlled study we followed 52 brain dead donors during transfer and carefully followed the oxygenation criteria of their lungs. We also extracted 23 matched brain dead donor's information retrospectively to form a historical control group. Three blood samples for arterial blood gases were collected immediately before and after transfer (T1 and T2) and 2 hours after an alveolar recruitment maneuver. (T3) We also obtained arterial blood gas test results from records with the same time interval in control group. Pvalue <0.05 was considered significant. Lung suitability criteria in blood gas sample for donation was a P/F ratio higher than 300. Results: There were no differences in age, cause of brain death, intubation days, presence of chest trauma, chest tube and the amount of fluid administered during transfer in case and control groups. (Table.1) PaO2/FIO2 at T1 and T2 also were not statistically different in both groups. PaO2/FIO2 dropped significantly after transfer (from 302.1 119.4 to 259 115.8 mmHg, p < 0.001) the transfer process turned 8 potential lung donors to inappropriate ones (4 in each group) which formed 17.4% of all donors. The only influencing factor was the amount of IV-fluid administered during transfer period with a positive correlation with PaO2/FIO2 drop (p = 0.02 and correlation coefficient = 0.540) The PaO2/FIO2 decrease from T1 to T3 was significantly lower in the recruitment maneuver group than in control group ( 4.3 44.1 vs 69.5 61.4 mmHg, p < 0.001). Conclusions: Transfer of brain dead donors from original hospitals to OPUs is associated with a decrease in PaO2/FIO2 and as a result the percentage of potential lung donors. This can be significantly reversed by a single alveolar recruitment maneuver immediately after hemodynamic stabilization. http://dx.doi.org/10.1016/j.ijt.2015.09.032 Abstract #: ISOT2015-52 Tissue matching index – A quantitative score for donor selection in organ transplantation Sonai Muthu, Sujata Mitra Tata Main Hospital, Jamshedpur 831001, India Background: Matching the two HLA antigens of class I and class II present in each locus has different significance in different organ transplantation. It is unanimously accepted that HLA identical (0MM) living related or cadaver grafts show a better survival than partially mismatched grafts. Matching hierarchy for renal transplantation is in the order of DR > B > A. Conventionally the donor in selected by counting the MisMatch (MM) scores. This MM scoring method has many disadvantages. Aims: This study has been done to develop a method to quantify the degree of HLA matching for renal transplantation in three loci comparison, and to apply in four, five and six loci comparisons. Methodology: A numerical method analogous to the positional number system has been developed to quantify the degree of HLA match between the recipient and the donor. Two terms, namely Tissue Matching Score (TMS) and Tissue Matching
59
Index (TMI) have been introduced and defined. TMS has been defined as the sum of locus weighted score assigned to each antigen match, when comparing the HLA of the recipient with that of the donor. Tissue Matching Index is defined as the ratio between the TMS obtained when comparing the HLA of the recipient with that of the donor and the value of TMS obtained in the best possible HLA match. For convenience, the value of Tissue Matching Index was expressed as percentage TMI by multiplying this ratio by hundred. The donor having the maximum value of TMI was considered as the best match. Results: In three loci (DR, B and A in renal transplantation) comparison, 27 possible scores of percent TMI are observed between 0 and 1. Each value of TMI is unique for every possible combination in the matching loci. In an ideal match, when all the antigens compared are exactly the same for the recipient and the donor, the value of TMI becomes one. This is equivalent to the conventional qualitative score of zero MisMatch (0 MM). In the worst match, where none of the donor Ts antigen matches with that of the recipient, the value of TMI becomes zero. This is equivalent to the conventional qualitative score of six MisMatch (6 MM). The MisMatch scores of 0 MM, 1 MM, 2 MM, 3 MM, 4 MM, 5 MM and 6 MM have 1,3,6,7,6,3 and 1 different values of percent TMI score respectively Maximum overlap of MM score is seen in 3MM score that could be donor could mean any one of the 7 possible combinations of TMI scores. There are 81, 243 and 729 discrete TMI scores observed in 4, 5 and 6 loci comparisons. Conclusions: Tissue Matching Index is useful in selecting the donor with scientifically acceptable degree of HLA match. It overcomes all the problems that are found in the conventional MM scoring method. This parameter can be easily used in combination with the other factors by the organ sharing networks. http://dx.doi.org/10.1016/j.ijt.2015.09.033 Abstract #: ISOT2015-88 Combined liver–kidney transplantation Prakash V. Chauhan, Pranjal R. Modi Institute of Kidney Diseases and Research Centre, Dr. HL Trivedi Institute of Transplantation Sciences, Ahmedabad, India Background: Liver transplantation has entered an era with increased survival. The renal morbidities are also becoming more common at long time. In both adult and paediatric group of patients chronic renal failure and end stage renal disease is a major factor that affects long term quality of life and hinders survival. The median waiting time for liver transplant recipients is now influenced by MELD scores. Potential recipients of liver transplant are subjected to develop clinically apparent nephropathy. Aims: To define various indications of transplant of liver and kidney at the same surgery. To discuss our centre experience of combined liver and kidney transplant. Methodology: Patients with liver and kidney dysfunction where operated for combined liver–kidney transplant. Two patients having primary oxalosis with renal dysfunction and other having cirrhosis with hepatorenal syndrome. Preoperative and postoperative renal and liver function parameters compared and analyzed. Results: Two Patients of primary oxalosis did well in postoperative phase. Liver enzymes settled down in 5 days. Serum creatinine came down from 3.98 mg/dl preoperative level to 0.53 mg/dl after surgery. Abdomen was kept opened due to severe oedematous abdominal organs in OT for 3 days. She was on CRRT for 4 days. Until renal function recovered. Subsequently abdomen wound closure done and patient
60
indian journal of transplantation 9 (2015) 47–60
discharged on 18th post-operative day. Another patient of cirrhosis with hepatorenal syndrome who underwent CLKT also maintained on CRRT during perioperative period after which his kidney function recovered and serum creatinine came down from 5 mg/dl of preoperative level to 1 mg/dl postoperatively. Liver enzymes also came to normal limits within one week. Conclusions: CLKT for hepatorenal syndrome is indicated in patients receiving haemodialysis for longer than 8 weeks and primary oxalosis confers advantages in patient survival. In CLKT liver is immunoprotective for the kidney as evidenced by less no of renal allograft rejection compared to renal transplant. http://dx.doi.org/10.1016/j.ijt.2015.09.034 Clinical spectrum of tuberculosis in renal transplant recipients S. Murugananth, R. Arul, T. Dineshkumar, J. Dhanapriya, R. T. Sakthirajan, N. Gopalakrishnan Madras Medical College, Chennai & Coimbatore Medical College, Coimbatore, India Aim: To assess the prevalence, risk factors and clinical profile of tuberculosis in renal transplant recipients. Material and methods: Patients who underwent renal transplantation at Rajiv Gandhi Govt. General Hospital from 2007 to 2014 were evaluated retrospectively. Patients with tuberculosis defined by demonstration of AFB in BAL/Sputum/Culture, body serous fluids analysis suggestive of tuberculosis, histopathological evidence of TB by FNAC/Excision biopsy and favourable response to anti TB drugs in those who had inconclusive evidence were included in the study. Those patients
who had proven tuberculosis in pre-transplant and continuing ATT in post transplant were excluded. Results: A total of 477 renal transplant patients were studied retrospectively, out of which 46 patients had tuberculosis. Of them 42 (91%) were males. 39 (84%) patients received kidneys from live related donors. Most patients received triple immunosuppression. Mean duration between transplantation and detection of tuberculosis was 23 months [range (1 month–10 yrs)]. About 66% (29/36) patients had pulmonary tuberculosis and 21% had pleural tuberculosis. Disseminated TB was diagnosed in 2 (4%) and TB lymphadenitis was found in 3 (6%) patients. TB pericarditis and TB meningitis were found in 1 patient each. 19% of patients had associated fungal infection and 19% had Hepatitis C virus infection. Cytomegalovirus (CMV) was found in 13%. Co-existing new onset diabetes after transplantation (NODAT) was found in 22%. In patients who had TB, 22% of them had previous history of antirejection therapy. 5% had past history of ATT and 5% had family history of TB. 60% of patients with pulmonary tuberculosis had positive yield by means of Sputum/BAL/culture. 4 patients died due to reasons directly attributed to TB (8%). 2 patients died to associated fungal infections. ATT induced hepatitis was found in 2 patients and optic neuritis in one patient. Conclusion: Prevalence of TB in our renal transplant recipients is 10%. Most of the patients developed tuberculosis more than 1 year after transplantation. Pulmonary tuberculosis was the most common form. NODAT, CMV, hepatitis C, fungal infections and antirejection therapy were found to be risk factors for post transplant tuberculosis. http://dx.doi.org/10.1016/j.ijt.2015.09.035