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Combined Liver and Kidney Transplantation, First Report from Pakistan with
Literature Review

Article in Journal of Clinical and Medical Research · October 2021

DOI: 10.37191/Mapsci-2582-4333-3(6)-091

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 Journal of Clinical and Medical Research
ISSN: 2582-4333
Dogar AW, et. al, 2021- J Clin Med Res
Case Report

1Organ Transplantation and HBP

Combined Liver and Kidney Department, Pir Abdul Qadir Shah Jeelani
Institute of Medical Sciences, Gambat,
Transplantation, First Report from Pakistan
Pakistan with Literature Review *Corresponding Author: Kaleem Ullah,
Senior Clinical fellow, Organ Transplant unit,
Abdul Wahab Dogar1, Kaleem Ullah1*, Shams Uddin1, Ali Pir Abdul Qadir Shah Jeelani Institute of
Husnain1, Ameer Hamza1, Syed Hasnain1, Azhar Hussain1, Medical Sciences, Gambat, Pakistan.
Hafiz Bilal1, Azam Shoaib1, Abdul Ghaffar1, Bilal ahmad1, Siraj
Khoso1, Hamid Raza Laghari1, Munazza Zafar1 and Asif Baig1 Accepted Date: 09-08-2021

Published Date: 10-08-2021

Abstract
Copyright© 2021 by Dogar AW, et. al. All
Combined Liver and kidney transplantation (CLKT) is the surgical rights reserved. This is an open access article
treatment modality for patients with combined end-stage Liver distributed under the terms of the Creative
and renal disease. Solo liver transplantation with underlying end- Commons Attribution License, which permits
stage Liver and renal disease leads to a poor prognosis. One of the unrestricted use, distribution, and
indication of CLKT is liver cirrhosis with irreversible renal failure. reproduction in any medium, provided the
However, several issues remain poorly understood with CLKT. It original author and source are credited.
is not clear to which extent renal transplantation affects liver
transplantation outcomes, and also, the long-term prognosis of combined procedure in cirrhotic patients is
not fully known.

The number of CLKT has been increasing over the past years in countries with advanced health care systems.
However, no such cases have been reported from Pakistan, a developing country with poor health care
facilities. Here we report the first CKLT from Pakistan.

Keywords: Combined; Liver transplantation, Cirrhosis, End-stage renal disease, Developing country.

Introduction disease (ESLD) and ESRD have benefited

from the combined transplantation [2]. One
Combined Liver and kidney transplantation of the indication of CLKT is liver cirrhosis
(CLKT) is the surgical treatment modality for with irreversible renal failure due to hepato-
patients with combined end-stage Liver and renal syndrome or chronic renal failure
renal disease. Solo liver transplantation with secondary to renal parenchymal diseases [3].
End-stage liver renal disease (ESRD) leads to Since the introduction of the MELD scoring
a poor prognosis [1]. Since the first-ever CLKT system, the trend of CLKT has been
in 1984, many patients with end-stage liver
Ullah K | Volume 3; Issue 6 (2021) | Mapsci-JCMR-3(6)-091 | Case Report
Citation: Dogar AW, Ullah K, Uddin S, Husnain A, Hamza A, Hasnain S, et al. Combined Liver and Kidney
Transplantation, First Report from Pakistan with Literature Review. J Clin Med Res. 2021;3(6):1-7.
DOI: https://doi.org/10.37191/Mapsci-2582-4333-3(6)-091
increasing worldwide. The reason is that the the last four years, having regular
people with deranged renal functions have maintenance hemodialysis twice-weekly for
higher MELD scores hence carry a higher the last three years. He, unfortunately, turned
probability of receiving CLKT [4,5]. out to be Hepatitis C (HCV) positive. He was
asymptomatic and did not take any antiviral
Combined transplantation gives the added therapy for HCV. Over time he developed
benefit of a single surgery, single anesthesia clinical decompensation with Ascites. His
exposure, common immunosuppression ECOG performance status was 01, Child Score
therapy, and better survival compared to of B 09, and MELD Na of 21. Fibro scan
separate organ transplantation, as reported in showed F4 fibrosis. Ultrasound abdomen
the literature [6]. However, several issues demonstrated hepatosplenomegaly, gross
remain poorly understood. It is not clear to ascites, and bilateral atrophic kidneys. CT
which extent renal transplantation affects scan abdomen was performed and found
liver transplantation outcomes. Also, the enlarged Liver with cirrhotic morphology,
long-term prognosis of combined procedure gross ascites, splenomegaly, and bilateral
in cirrhotic patients is not fully known. The shrunken kidneys.
existing evidence is limited because most
published series of patients treated with This case was taken to the multi-disciplinary
CLKT include a significant number of patients department meeting where surgical,
with metabolic liver disease without cirrhosis. hepatology, nephrology, anesthesia,
CLKT patients have reported being at higher radiology, and cardiology team participated.
risk of getting bacterial infections. Also, The decision to combine Liver and kidney
prolonged ICU and hospital stay, high transplants was taken and conveyed to the
frequency of post-operative complications, patient and his family. The details of the
and poor short-term outcomes are noted workup, surgical procedure, possible
compared to single transplantation [7,8]. outcome, and peri-operative care and follow-
up were explained to him.
The number of CLKT has been increasing
over the past years in countries with advanced Separate workup for Liver and kidney donors
health care systems. However, no such cases was initiated after suitable initial donor
have been reported from Pakistan, a selection according to the local human organ
developing country with poor health care transplant act (HOTA). Detailed history and
facilities. clinical examinations of both donors were
made. Detail of the donor surgical procedure,
Here is the first case report from Pakistan as its possible morbidity, and mortality was
a novel experience of CLKT. explained. Complete insight into the
Case Presentation magnitude of the surgery and self-volunteers
was confirmed with complete privacy.
A thirty-one-year-old male weighing 58 kg Laboratory investigations, including
and BMI of 18.3, a known case of ESRD thrombophilia workup screening, were done.
secondary to hypertensive nephropathy for For the liver donor, a triphasic CT scan was
Ullah K | Volume 3; Issue 6 (2021) | Mapsci-JCMR-3(6)-091 | Case Report
Citation: Dogar AW, Ullah K, Uddin S, Husnain A, Hamza A, Hasnain S, et al. Combined Liver and Kidney
Transplantation, First Report from Pakistan with Literature Review. J Clin Med Res. 2021;3(6):1-7.
DOI: https://doi.org/10.37191/Mapsci-2582-4333-3(6)-091
performed to delineate the vascular anatomy, anastomosed with polypropylene 8/0, and
volumetry, and graft characteristics, also finally, the hepatic duct was anastomosed
MRCP was performed to know the biliary with PDS 6/0. Post implantation doppler
anatomy. For kidney donors, a contrast- study was performed, which showed patent
enhanced CT scan was performed for graft lumens and blood flow in hepatic and renal
characteristics and vascular anatomy. HLA vasculature.
typing, complement-dependent cytotoxicity,
and a diethylene triamine Penta acetic acid Per-operatively, fluid management was done
(DTPA) scan was performed. judiciously, which was guided by a PICCO
monitor and trans-esophageal
Both the donors were matched with the echocardiography. No metabolic acidosis was
recipient regarding graft characteristics, experienced during the whole procedure.
vascular anatomy. For liver donation, right Postoperatively the patient was shifted
lobe graft without MHV, weighing 545 grams, ventilated to ICU. During his stay in ICU, he
GRWR of 0.93, and for reconstruction, single was managed with fluids, inotropic support,
right hepatic vein, right hepatic artery, right antibiotics, chest care, and physiotherapy.
portal vein, and the right hepatic duct was His strict monitoring was done, including
used. For kidney donation, the left kidney vitals, ECG, drain output, intake (fluids and
with a single artery and vein was taken. oral), and urine output. He was extubated the
following day due to minimal ventilatory
Renal dialysis was done on the day before settings, normal metabolic acid-base
surgery. On the day of the procedure, first parameters, and confirmatory routine
kidney transplantation was performed. The
Doppler ultrasound for hepatic and renal
donor's left kidney was implanted extra- vasculature. The patient was started on an
peritoneally in the left iliac fossa. The renal immunosuppressant oral Tacrolimus 1 mg
artery was anastomosed with a 7/0 bid, oral Mycophenolate Mofetil 1gm BD, and
polypropylene with external iliac artery in the Methylprednisolone. The dose of tacrolimus
end-to-side fashion. The renal vein was was adjusted according to its serum level. The
anastomosed with a 5/0 polypropylene with
patient remained in ICU for ten days, while
the external iliac vein in the end to side the total hospital stay was 15 days. He was
fashion. The ureter was anastomosed directly discharged on the 15th post-operative day,
with a urinary bladder over a DJ stent. and during his stay in the hospital, he did not
Adequate urinary output was noted at the end meet with any complications or adverse
of the procedure. events. He was initially followed up weekly for
The abdomen was then opened with a four weeks, then two weekly for two months.
Mercedes Benz incision, and after the From the 3rd month onward, he was followed
recipient's hepatectomy Right lobe graft was up for three months till one year. During this
implanted. The hepatic vein was follow-up, his liver status was found to be
anastomosed with IVC using proline 5/0, fine, but his creatinine was raised twice, for
portal vein was anastomosed with which the tacrolimus dose needed to adjust.
polypropylene 5/0, the hepatic artery was The patient is still on follow up doing well.
Ullah K | Volume 3; Issue 6 (2021) | Mapsci-JCMR-3(6)-091 | Case Report
Citation: Dogar AW, Ullah K, Uddin S, Husnain A, Hamza A, Hasnain S, et al. Combined Liver and Kidney
Transplantation, First Report from Pakistan with Literature Review. J Clin Med Res. 2021;3(6):1-7.
DOI: https://doi.org/10.37191/Mapsci-2582-4333-3(6)-091
 Laboratory Result Reference range
3
WBC (cells/mm ) 8330 4000-11000
Hemoglobin (g/dl) 8.6 11.5-15
Platelet count (cells/mm3) 239×109 150-400*109
Albumin (g/dl) 2.6 3.4-5
Total bilirubin (mg/dl) 1.4 1.2-2
Aspartate aminotransferase (U/L) 74 <45
Alanine aminotransferase (U/L) 60 9.4-36
International normalized ratio 1.5 -
Creatinine (mg/dl) 7.4 0.5-1.3
Table 1: Pre-operative laboratory parameters of the patient.

Discussion organ failure due to isolated pathologies are

the two common most indications for CLKT
Renal dysfunction is commonly observed in
[13]. In this case, the patient was also having
patients with ESLD. The outcome of solo liver dual organ failure with isolated pathologies,
transplantation in cases with renal failure is ESRD secondary to HTN and ESLD secondary
associated with higher complications and to Hepatitis C.
mortality rates as compared to combine
transplantation [9,10]. Immunosuppressant In metabolic diseases, the defective liver
(calcineurin inhibitors) use, procedure- damages the normal kidneys and causes its
related hemodynamic insults, and sepsis are failure. It looks logical to do CLKT in such
the main causes for this poor outcome of solo cases. But some authors favor sequential
liver transplantation [10]. Also, post-liver transplantation. Performing liver
transplant dialysis leads to vascular catheter- transplantation first gives the advantage of
related sepsis resulting in high mortality. correcting the primary pathology. While
Similarly, solo renal transplantation puts repeated dialysis reduces the load of
compensated cirrhotic patients at risk of post- nephrotoxic metabolites ahead of renal
operative liver decompensation [11]. transplantation [14,15]. However, in the
scenario of deceased donor availability, CLKT
The decision for CLKT often becomes difficult becomes a good choice with added
when renal dysfunction is temporary as advantages of a single donor and single
observed in hepatorenal syndrome (HRS) or surgery. Also, the recipient will get a common
acute renal failure in the background of ESLD. immunosuppression regime [6]. It is also
The good recovery of renal functions might be proposed that the liver has a protective effect
expected only if early liver transplantation is over kidney graft secondary to phagocytosis
done as the lengthy waiting period will of the reactive antibodies by liver Kupffer cells
further worsen the kidney functions [11]. Few and also by the secretion of human leukocyte
criteria have been published to guide and antigens by the hepatocytes [11,13].
help in decision-making [9,8,12]. ESRD
secondary to metabolic liver disease, and dual

Ullah K | Volume 3; Issue 6 (2021) | Mapsci-JCMR-3(6)-091 | Case Report

Citation: Dogar AW, Ullah K, Uddin S, Husnain A, Hamza A, Hasnain S, et al. Combined Liver and Kidney
Transplantation, First Report from Pakistan with Literature Review. J Clin Med Res. 2021;3(6):1-7.
DOI: https://doi.org/10.37191/Mapsci-2582-4333-3(6)-091
Regarding 5-survival, better survival (64%) patients with severe acidosis, prolonged
was observed with CLKT compared to anhepatic phase, fluid overload, and
sequential transplant (53.3%) [11,16,17]. hyperkalemia [21,22]. Problems with
However, the study of M.E. Baccaro et al. CVVHDF are filter clotting, air embolism,
reported that in patients with CLKT there was hypotension, and postoperative vascular
a higher incidence of post-operative thrombosis. If there are no signs of fluid
infections and relatively lower 1-year survival overload or in cases with a shorter anhepatic
rates as compared to long-term 3- and 5-year phase, the acidosis can be managed with
survival rates. Low 01-year survival rates were sodium bicarbonate boluses [19].
largely attributed to postoperative infections
and sepsis mostly due to rigorous use of Due to limited donors’ availability, it is very
immunosuppressants [18]. However, our crucial to select recipients with clear
patient did not report any post-operative indications for CKLT. Also, patients with
septic event, which might be due to optimal acute kidney injury are considered for CLKT
immunosuppressant levels. if they fulfill specific criteria [12]. Our patient
had CKD with very low GFR and renal biopsy
CLKT is a challenging task regarding confirmed the presence of >30% glomerular
anesthesia and critical care management due sclerosis due to longstanding hypertensive
to multi-organ dysfunction [19]. The ESLD is nephropathy. Following guidelines, we
often associated with pulmonary considered this patient for CLKT. The 03
hypertension, hepato-pulmonary syndrome, month and 06 months follow-ups were
HRS, pericardial effusion, coagulopathy, and normal and the good outcome of this patient
electrolytic imbalance like hypocalcemia and was highly encouraging for our team.
hyponatremia. The combined illness reduces
substantial drug metabolism and also causes Conclusion
significant acidosis. The major concern Patients with the significant renal
during the CLKT procedure is fluid parenchymal disease along with concomitant
management. In the pre-anhepatic phase advanced liver disease are suitable candidates
restricted fluid replacement with CVP 2-5 mm for CLKT. Proper indication with good
Hg is recommended [20,21]. In this case fluid optimization and better perioperative care,
management was guided by PICCO device especially anesthesia and critical care
and Trans-esophageal echocardiography management are the keys to a good outcome
which are the ideal devices for fluid in such challenging cases. We encourage
management in such sort of challenging others centers of the country to proceed with
cases. CKLT in indicated cases or refer them to
Continuous Ven venous hemodiafiltration experience centers.
(CVVHDF) is indicated for non-optimized

Ullah K | Volume 3; Issue 6 (2021) | Mapsci-JCMR-3(6)-091 | Case Report

Citation: Dogar AW, Ullah K, Uddin S, Husnain A, Hamza A, Hasnain S, et al. Combined Liver and Kidney
Transplantation, First Report from Pakistan with Literature Review. J Clin Med Res. 2021;3(6):1-7.
DOI: https://doi.org/10.37191/Mapsci-2582-4333-3(6)-091
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Ullah K | Volume 3; Issue 6 (2021) | Mapsci-JCMR-3(6)-091 | Case Report
Citation: Dogar AW, Ullah K, Uddin S, Husnain A, Hamza A, Hasnain S, et al. Combined Liver and Kidney
Transplantation, First Report from Pakistan with Literature Review. J Clin Med Res. 2021;3(6):1-7.
DOI: https://doi.org/10.37191/Mapsci-2582-4333-3(6)-091
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Ullah K | Volume 3; Issue 6 (2021) | Mapsci-JCMR-3(6)-091 | Case Report

Citation: Dogar AW, Ullah K, Uddin S, Husnain A, Hamza A, Hasnain S, et al. Combined Liver and Kidney
Transplantation, First Report from Pakistan with Literature Review. J Clin Med Res. 2021;3(6):1-7.
DOI: https://doi.org/10.37191/Mapsci-2582-4333-3(6)-091

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