A Novel Approach in Combined Liver and Kidney Transplantation with Long-term Outcomes

Burcin Ekser, Richard S. Mangus, W. Fridell, Chandrashekhar A. Kubal, Shunji Nagai, Sandra B. Kinsella, Demetria R. Bayt, Teresa M. Bell, John A. Powelson, William C. Goggins, A. Joseph Tector

Research output: Contribution to journalArticlepeer-review

32 Scopus citations


Objective: The aim of this study was to compare the outcomes of simultaneous and delayed implantation of kidney grafts in combined liver-kidney transplantation (CLKT). Background Data: Delayed function of the renal graft (DGF), which can result from hypotension and pressor use related to the liver transplantation (LT), may cause worse outcomes in CLKT. Methods: A total of 130 CLKTs were performed at Indiana University between 2002 and 2015 and studied in an observational cohort study. All kidneys underwent continuous hypothermic pulsatile machine perfusion until transplant: 69 with simultaneous kidney transplantation (KT) (at time of LT, group 1) and 61 with delayed KT (performed at a later time as a second operation, group 2). All patients received continuous veno-venous hemodialysis during the LT. Propensity score match analysis in a 1:1 case-match was performed. Results: Mean kidney cold ischemia time was 10 ± 3 and 50 ± 15 hours, for groups 1 and 2 (P < 0.0001), respectively. The rate of DGF was 7.3% in group 1, but no DGF was seen in group 2 (P = 0.0600). Kidney function was significantly better in group 2, if the implantation of kidneys was delayed >48 hours (P < 0.01). Patient survival was greater in group 2 at 1 year (91%), and 5 year (87%) post-transplantation (P = 0.0019). On multivariate analysis, DGF [hazard ratio (HR), 165.7; 95% confidence interval (CI), 9.4-2926], extended criteria donor kidneys (HR, 15.9; 95% CI 1.8-145.2), and recipient hepatitis C (HR, 5.5; 95% CI 1.7-17.8) were significant independent risk factors for patient survival. Conclusions: Delayed KT in CLKT (especially if delayed >48 h) is associated with improved kidney function with no DGF post-KT, and improved patient and graft survival.

Original languageEnglish (US)
Pages (from-to)1000-1008
Number of pages9
JournalAnnals of surgery
Issue number5
StatePublished - May 1 2017
Externally publishedYes


  • cold ischemia time
  • combined liver and kidney transplantation
  • delayed graft function
  • kidney transplantation
  • liver transplantation
  • pulsatile perfusion

ASJC Scopus subject areas

  • Surgery


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