HCV Infection and Kidney Transplantation in 2014
HCV Infection and Kidney Transplantation in 2014
One difficult issue in the field is when to perform CKLT versus kidney transplantation alone (KTA) in the ESRD patient with HCV cirrhosis. Patients with ESRD and decompensated HCV-related liver cirrhosis should be listed for CKLT. However, there is an ongoing debate about patients with compensated liver cirrhosis, that is, those with preserved liver function. Since the introduction of the Model for End-Stage Liver Disease (MELD) score in 2002, numbers of CKLT have risen substantially. The MELD score includes renal function (creatinine), dialysis in the previous week, bilirubin and international normalized ratio (INR). As ESRD patients may have a high MELD score even with normal liver function (bilirubin and INR), they might qualify for CKLT in spite of being "not sick enough." The additional benefits of dual organ transplantation in these patients are unknown and difficult to assess. It also raises some ethical concerns about possible overindication of liver transplantation in that setting.
Especially when SVR has been achieved after HCV treatment and no other co-morbidities are present, it is possible that liver function will remain stable over a long period. The 2008 KDIGO guidelines suggest considering these patients for KTA, but under an investigational protocol. An American consensus conference on CKLT in 2008 proposed using the presence of significant portal hypertension, defined as an HVPG of ≥10 mmHg, as a contraindication for KTA in ESRD patients. Paramesh et al reported the experience of nine patients with biopsy-proven HCV cirrhosis with HVPG < 10 mmHg who underwent KTA. Compared to 28 HCV-infected kidney transplant recipients without cirrhosis, there was no significant difference in patient and allograft survival rates in the first 3 years, with elderly age and decreasing albumin levels associated with worse survival. An American transplant registry analysis showed for patients (HCV-infected or -negative) with both ESRD and end-stage liver disease, superior patient and allograft survival after CKLT as compared to serial kidney-after-liver or liver-after-kidney transplantation. However, larger prospective studies are still needed to standardize the criteria for CKLT.
When Should Combined Liver–Kidney Transplantation Be Considered?
One difficult issue in the field is when to perform CKLT versus kidney transplantation alone (KTA) in the ESRD patient with HCV cirrhosis. Patients with ESRD and decompensated HCV-related liver cirrhosis should be listed for CKLT. However, there is an ongoing debate about patients with compensated liver cirrhosis, that is, those with preserved liver function. Since the introduction of the Model for End-Stage Liver Disease (MELD) score in 2002, numbers of CKLT have risen substantially. The MELD score includes renal function (creatinine), dialysis in the previous week, bilirubin and international normalized ratio (INR). As ESRD patients may have a high MELD score even with normal liver function (bilirubin and INR), they might qualify for CKLT in spite of being "not sick enough." The additional benefits of dual organ transplantation in these patients are unknown and difficult to assess. It also raises some ethical concerns about possible overindication of liver transplantation in that setting.
Especially when SVR has been achieved after HCV treatment and no other co-morbidities are present, it is possible that liver function will remain stable over a long period. The 2008 KDIGO guidelines suggest considering these patients for KTA, but under an investigational protocol. An American consensus conference on CKLT in 2008 proposed using the presence of significant portal hypertension, defined as an HVPG of ≥10 mmHg, as a contraindication for KTA in ESRD patients. Paramesh et al reported the experience of nine patients with biopsy-proven HCV cirrhosis with HVPG < 10 mmHg who underwent KTA. Compared to 28 HCV-infected kidney transplant recipients without cirrhosis, there was no significant difference in patient and allograft survival rates in the first 3 years, with elderly age and decreasing albumin levels associated with worse survival. An American transplant registry analysis showed for patients (HCV-infected or -negative) with both ESRD and end-stage liver disease, superior patient and allograft survival after CKLT as compared to serial kidney-after-liver or liver-after-kidney transplantation. However, larger prospective studies are still needed to standardize the criteria for CKLT.
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