一系列案例顯示肝腎合併移植手術有助於兩器官皆罹病病患


  August 25, 2006 -- 根據一篇系列案例回溯分析結果,肝腎合併移植手術(CLKT) 一般被建議用於肝腎均末期疾病之病患,似乎也可用於肝腎症候群(一種因肝臟疾病導致的潛在的可逆的腎衰竭)而接受血液透析(HD)超過兩個月的病患。
  
  當肝腎合併移植手術在一個高容量大學移植中心進行時,可提供同時發生慢性肝腎衰竭之病患最佳選擇,這群研究者是由當時在Dumont-UCLA移植中心、而現在服務於Baylor 大學的Richard Ruiz醫師所領導,在八月版的Archives of Surgery期刊中有上述發表;對接受移植前透析超過兩個月的肝腎症候群病患進行兩個器官的移植,似乎可以提供病患存活利益,而且肝臟可對腎臟移植提供免疫保護。
  
  凱斯西儲大學醫學院的Donald E. Hricik 醫師表示,這是一個重要的、對此手術有豐富經驗的單一中心經驗,但坦白說,我們還需要更多資料以對此結論定調;Hricik醫師未參與此研究,不過同意為Medscape對此結果提出建議。
  
  【完成更多的合併移植】
  首次的肝腎同時移植在1983年進行,而目前這已是兩個器官均末期疾病之病患的治療首選;在2002年導入末期肝病模式 (Model for End-Stage Liver Disease,MELD)器官分配規範之後,移植候補者的血清肌酸酐越高,就可以更快獲得器官,使肝腎合併移植手術的案例已漸漸增加。
  
  他們針對在他們的大型醫學中心此種合併手術的案例進行回顧,試圖找到規範以擴大成功率。
  
  他們檢視1988到2004年間的98位病患(89 位成人)、進行肝腎合併移植手術的資料;76 位仍有原發腎臟病,22 位有肝腎症候群,他們比較這些病患和其他僅有進行肝臟移植或者大體腎臟移植的病患。
  
  【傑出的結果】
  合併移植手術的的整體結果是「傑出的」,在長達五年之後,不論病患或其接受之器官仍有高存活率。
  

終點

一年存活率 (%)

3 年存活率 (%)

5 年存活率 (%)

病患

76

72

70

肝臟移植物

70

65

65

腎臟移植物

76

72

70


  
  有肝腎症候群者病患之中,洗腎超過八週者一年存活率(88%)比少於八週者(64%)更佳。
  
  成年移植病患中,合併移植者一年的腎臟移植物排斥率(14%)比僅接受腎臟移植者的排斥率(23%)為低(P < .01)。
  
  該團隊指出他們達成兩個規範結論:第一,病患接受短期(少於30天)移植前洗腎且恢復腎功能者,僅需接受肝臟移植;第二,病患接受 HD 超過 8週, CLKT對存活利益和資源利用均提供好處。
  
  【仍有問題未解決需要加以規範】
  Hricik醫師指出,實際的問題是那些等候移植而洗腎期間在30天到八週之間者,這樣的大型觀察資料看來是有幫助的,但是對於介在這兩個時間點之間的病患來說,仍有某些問題懸而未決。
  
  他指出,等候捐肝者的期間相當長,而在肝臟移植後肝腎症候群症狀不一定會有所改善,所以才需要規範。
  
  Hricik醫師表示,使此議題受大眾關注的原因是,是否可以將大體腎臟撥一部分給肝病患者、而大多數有一級腎臟病;等待腎臟移植者取對於得大體腎臟捐贈已有困難,每一次進行肝臟移植時若肌酸酐升高,是否就要「丟」一個腎臟給病患,這一點需嚴肅以對。
  
  在對篇文章的小組討論中,加州大學舊金山分校的John P. Roberts醫師表示,首先恭喜作者們獲得傑出的病患和移植的器官存活率,但應持續討論在器官捐贈短缺之下使用合併移植的相關問題。
  
  Roberts醫師指出,對這些人來說,怎樣才是對腎臟的最佳利用仍有極大的爭議,需預防可能的器官浪費,例如肝衰竭併急性腎衰竭病患若接受腎臟移植且漸漸恢復腎臟功能,則其體內會有3顆功能正常的腎臟。
  
  研究之共同作者、Dumont-UCLA移植中心的 Ronald W. Busuttil醫師表示,他們的確有多位病患有3顆功能正常的腎臟,此一事實強調了需要CLKT特定的術前、預後指標的重要性;假定指標包括肌酸酐值、寡尿或無尿的程度、MAG-3掃描的結果,這些都未經嚴格檢驗、也無高度可預測值,是此一議題的重要關鍵,我們認為接受HD八週以上才需開始考量。
  
  該團隊正著手描述MELD制度如何影響器官分配。
  

Liver-Kidney Transplants Benef

By Marlene Busko
Medscape Medical News

August 25, 2006 — A combined liver-kidney transplant (CLKT) is recommended for patients with end-stage disease in both organs and seems warranted for patients with hepatorenal syndrome (a potentially reversible renal failure caused by liver disease) receiving hemodialysis (HD) for more than 2 months, according to a retrospective case series.

"Combined liver and kidney transplantation offers the best option for patients with simultaneous chronic liver and kidney failure, when it is performed at a high-volume academic transplant center," the researchers, led by Richard Ruiz, MD, now at Baylor University in Dallas, Texas, but with the Dumont-UCLA Transplant Center at the University of California, Los Angeles at the time of this study, report in the August issue of the Archives of Surgery. In patients with hepatorenal syndrome, dual-organ transplantation seems to confer survival advantages in those who receive 2 months of pretransplant dialysis, and the liver is immunoprotective for kidney transplants, they add.

"This is an important single-center experience from a center that had a lot of experience with this, but frankly we still need more data to fine-tune their conclusions," said Donald E. Hricik, MD, from Case Western Reserve College of Medicine in Cleveland, Ohio. Dr. Hricik was not involved in this research but agreed to comment on the results for Medscape.

More Combined Transplants Being Done

The first simultaneous liver and kidney transplant was performed in 1983, and this is now the procedure of choice for patients with end-stage disease in both organs, the investigators explain. There has been a considerable increase in the number of combined kidney-liver transplants performed following the 2002 introduction of the model for end-stage liver disease (MELD) organ-allocation system, in which candidates with high serum creatinine receive organs more rapidly, they add.

They aimed to review their experience with the combined procedure at their large medical center and look for guidelines to maximize success.

They examined data from 1988 to 2004 from 98 patients (89 adults) who underwent combined liver and kidney transplants; 76 had primary renal disease, and 22 had hepatorenal syndrome. They compared these patients with others who underwent only liver transplant or cadaveric renal transplant.

Excellent Outcomes

Overall outcomes of the combined transplants were "excellent," they write, with high patient and graft survival rates out to 5 years.

End Point
1-y survival (%)
3-y survival (%)
5-y survival (%)
Patients
76
72
70
Liver grafts
70
65
65
Kidney grafts
76
72
70


Among patients with hepatorenal syndrome, 1-year patient survival was better in those with HD of more than 8 weeks (88%) vs 8 weeks or less (64%).

Among adult transplant recipients, 1-year kidney graft rejection was lower in the patients who received combined transplants vs those who received kidneys only: 14% vs 23%, P < .01.

The team writes that they arrived at 2 guideline conclusions: "First, there is eventual return of native kidney function for patients receiving short-term (less than 30 days) of pretransplantation HD who undergo [liver transplantation] LT only. Second, for patients receiving HD longer than 8 weeks, CLKT confers advantages regarding survival and resource use."

Unanswered Questions Remain, Guidelines Needed

The real problem is transplant candidates who are on dialysis between 30 days and 8 weeks, Dr. Hricik pointed out. "This observation from one of the bigger centers was helpful, but it still leaves some unanswered questions about those patients who fall in between those 2 categories."

He added that waiting times for donor livers are getting ever longer, and it is now known that hepatorenal syndrome does not always improve after a liver transplant, so guidelines are needed.

"What makes this an area of public concern is whether we are going to be siphoning off a large fraction of the pool of cadaver kidneys to be giving them to people with liver disease, as opposed to the much larger group of patients who have primary kidney disease only," Dr. Hricik said. "We already have a crisis of availability of cadaver donors for those waiting for kidney transplants, and it's important that people look critically at whether we should just throw a kidney in every time we do a liver transplant because they have an elevated creatinine."

In a discussion section following the article, Dr. John P. Roberts, from the University of California, San Francisco, congratulates the authors on their excellent patient and graft survival rates but also goes on to discuss some of the issues raised by using combined transplants in terms of the current shortage of donor organs.

"The tension between competing groups of patients has created great controversy over the best use of kidneys in these populations," Dr. Roberts writes. "One preventable waste of organs would be to have a patient who had liver failure and acute kidney failure who received a kidney transplant but then went on to recover native kidney function, resulting in the patient with 3 functioning kidneys."

Study coauthor Ronald W. Busuttil, MD, also

    
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