Anaesthesia for Living Donor Combined Liver Kidney

Transplantation

Case Report

INTRODUCTION

With advances in transplantation, multiorgantransplantation has become a treatment of choice for end-stage organ failure which can not be reversed with othermodalities. In 1984, Margreiter, et al [2] performed thefirst combined kidney and liver transplantation. Patientswith renal failure after liver transplantation have aparticularly poor prognosis. Therefore, in the setting ofend-stage renal disease requiring dialysis or severe renalinsufficiency that will not improve after liver replacement,combined liver-kidney transplantation (CKLT) is thepreferred approach.

We report such a case below.

CASE REPORT

A 44 year old man presented to the Apollo Hospital, NewDelhi, with history of jaundice for three and half years,fatigue and fever for one year, decreased urine output for twoweeks. He complained of one episode of hematemesis 3 daysback. Patient gave history of alcohol abuse and abstinencefor more than two years. Ultrasound abdomen showedcirrhosis of liver, ascites with portal hypertension. Otherinvestigations are shown in (Table 1). During the course inhospital he was put on hemodialysis. He was managedconservatively for hematemesis & deteriorating level ofconsciousness. In spite of best medical efforts his conditiondid not improve. Case was discussed in multidisciplinary

ANAESTHESIA FOR LIVING DONOR COMBINED LIVER KIDNEY TRANSPLANTATION

Sanjeev Aneja* and Sharadkumar Upwar***Senior Consultant in Anesthesia, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India,

**Consultant Anesthetist, Apollo Hospitals, E-2, Sector 26, Noida 201 302, India.Correspondence to: Dr Sanjeev Aneja, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India.

E-mail: sanjeevaneja@hotmail.com

Orthotopic liver transplantation is now the best therapeutic option for patients with chronic liver failure [1]. Livertransplant is now a routine surgery performed in numerous medical centers throughout the world. Till nowabout 600 liver transplants have been performed in the Indraprastha Apollo Hospital, New Delhi. Combinedliver kidney transplantation (CKLT) is the treatment for end-stage liver and kidney diseases. Combined liverkidney transplantation from living donors is performed in very few centers. Not many cases of Living donorcombined Liver Kidney transplantation has been described in the literature. Here we report the clinicalexperience of our first living donor combined liver kidney transplantation (kidney after liver) in patient with end-stage liver disease (ESLD) and end stage renal failure (ESRD). Liver and kidney graft has been harvestedfrom two living related donors.

Keywords: Combined liver kidney transplantation, Living related liver kidney transplantation.

liver transplantation meeting and live related combinedliver and kidney transplantation was considered. Family ofpatient was counseled, they were given all therapeuticoptions i.e. combined vs sequential combined liver kidneytransplantation. Family opted for combined liver kidney

Table1. Laboratory investigations

Hb: 8.8 gm% Sr Sodium- 141 mEq/litTLC- 12000/ cmm Sr. Potassium- 3.7 mEq/litPlatelet- 64000/ cmm Sr. Calcium- 9.0PT- 26.8/ 11.8 sec Sr. Phosphorus- 6.9INR- 2.3 AST/ALT- 54/26 U/LPTT- 34.3/33 Creatinine clearance-27 mL/

minUrea- 144 Direct bilirubin -2.4mg/dLCreatinine- 4.1 Alkaline phosphatase- 63 U/LHBsAg- Negative Urine protein/creatinine ratio

6.3Anti HCV- Positive Urine spot sodium 40 mEqHIV I, II- Negative Fibrinogen level- 75 mg/dLCMV IgG- Reactive FDP- >20 microIU/mLABG on room Air-pH 7.38, pCo228mmHg, pO2 89mmHg, HCO3 18,BE 0.1, O2 sat 95%

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transplant. Two different donors in the family were willingto share their organs with the patient. Modified Child-Pughclassification score is 14-Grade C (Table 2) Model for EndStage Liver Disease (MELD) Score: 40 points (Sr Bilirubin16 mg/dL, INR 2.3, Sr Creatinine 4.1+ history of dialysis).

Complete cardiac evaluation was done: Dobutaminestress echo was negative for ischemia, LVEF 65%,pulmonary artery systolic pressure 35mmHg.

He underwent hemodialysis a day before surgery. Bodyweight of the patient was 60 kg. He was on antibiotics,antifungal and proton inhibitors. Blood products werearranged as per transplant protocol (10 units of PRC, 15,units of FFP, 2 single donor plasma, 2 single donor plateletsand 4 cryoprecipitate were arranged). Hemodialysismachine was arranged to be made available in the theatrefor intraoperative dialysis if needed.

On the day of surgery patient was shifted to designatedoperating room with all facilities for warming & infusinglarge volume of fluid quickly. All monitors were appliedas per standard guidelines.

Left redial artery was cannulated with 20G cannulaunder local anesthesia. After preoxgenation rapidsequence induction was done with inj fentanyl 300 mcg (5mcg/kg), inj propofol 120 mg (2 mg/kg), and injsuxamethonium 75 mg (1.5 mg/kg). Trachea wasintubated with 8.5 mm internal diameter size endotrachealtube. Right internal jugular vein cannulated with triplelumen catheter and 8F size sheath. Pulmonary arterycatheter was inserted for pulmonary artery pressuremonitoring. For intraoperative dialysis right subclavianvein cannulated with dialysis catheter. Anaesthesia wasmaintained with oxygen, air, isoflurane, inj Atracuriuminfusion 0.5mg/kg/hr, fentanyl infusion 2 mcg/kg/hr.Patient was monitored using electrocardiogram (ECG),ST segment analyzer, pulse oximeter, capnometer, centralvenous pressure, pulmonary artery pressure, cardiacoutput, arterial blood pressure, temperature and urineoutput. Core body temperature was maintained byconvective warmer, warming mattress, warm intravenous

fluids using HOTLINE (Rapid Infusion). Coagulationparameters were observed with hourly Prothombin time(PT), INR, aPTT and thromboelastograph (TEG). HourlyABG, Hb, PCV, platelet count was done. Based on thesereports blood and blood products were administered as perdepartmental protocol. (To keep Hb ≥8 gm%, INR 1.5-1.8,Platelets as per TEG and surgical bleeding).

At the end of dissection phase hemodialysis wasstarted to correct metabolic acidosis and to correct fluidstatus, to make the ideal conditions for new liver. Rightlobe liver graft of the donor transplanted orthotopically.Patient tolerated the anhepatic and reperfusion phase well.Hypotension was treated with nor-adrenaline infusion,and boluses of phenylepherine. After the successfulcompletion of hepatic artery anastomosis the donor kidneywas harvested from another donor and transplanted extraperitoneally in left iliac fossa. Patient showed good liverand kidney graft function on the table as indicated by bileproduction, good urine output and correction of metabolicacidosis.

The total operative blood loss was 2500 mL andpatient received 12 units of packed red cells.

Postoperatively patient was monitored in intensivecare unit. He was on elective mechanical ventilation andtrachea extubated 10 hours postoperatively. Forpostoperative pain inj morphine given 3 mg intravenouson PRN basis. Immunosuppressant regimen includes injmethyl prednisone, tacrolimus (pan graf) andmycophenolate mofetil (cellcept). Liver and kidney graftfunction has been assessed by INR and Sr Creatinine (Fig1). No episode of acute rejection was encountered.Postoperative course was uneventful and patient wasdischarged on 20th day postoperatively.

DISCUSSION

The first liver combined liver kidney transplantation(CLKT) was reported by Margreiter, et al [2] in 1984.

Fig 1. Postoperative liver and kidney graft function.

Table 2. Child-pugh classification

Parameter Points

Ascites Moderate 3Bilirubin 16 mg/dL 3Albumin 2.3 gm/dL 3Prothmbin time (INR) 26.8 (2.3) 3Encephalopathy Grade 2 2

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Several authors [3-5] subsequently demonstrated thefeasibility and safety of combined transplantation andfavorable outcome in patients with end stage liver diseaseassociated with renal failure. Most of these CLKT arecadaveric and living related combined liver kidneytransplantation is very few in number [6]. This is firstCLKT in our series of 500 liver transplantations.

There is a debate on indications for CLKT and whetherhepatorenal syndrome is an indication for CLKT [7, 8].The Consensus Conference on Simultaneous Liver KidneyTransplantation [ 9] agreed on the premise that patientswith following parameters should be an indication forcombined liver kidney transplantation (CLKT) (i) ESRDpatients with cirrhosis and symptomatic portalhypertension or hepatic vein wedge pressure with gradientgreater than 10 mm Hg; (ii) patients with ESLD and chronickidney disease with GFR ≥30 mL/min; (iii) patients withacute kidney injury(AKI) including hepatorenalsyndrome(HRS) with creatinine ≥2.0 mg/dL and dialysis≥8 weeks; and (iv) patients with ESLD and evidence ofchronic kidney disease(CKD) and kidney biopsydemonstrating >30% glomerulosclerosis or 30% fibrosis.

The operation is considered in three phases. Thepreanhepatic phase is when the liver is mobilized, theanhepatic phase when the liver is removed and the third orneohepatic phase is when the new liver graft is reperfusedand the operation completed. Each phase requires carefulconsideration by the anaesthesiologist.

From a surgical - technical point a combined liver andkidney transplantation is usually not more complicated thana liver transplant; however the procedure is of course moretime consuming than a regular liver transplant. The liver istransplanted first followed by the kidney from anotherdonor. The risk of intraoperative and post operativebleeding must be considered and the risk of acute tubularnecrosis post-transplant. This risk should theoretically notbe higher than after any kidney transplantation but somesort of kidney assisting device i.e., hemodialysis should beused during the liver transplant in order to optimize thefluid and electrolyte balance i.e., potassium and circulatorystatus. The timing of dialysis may be at the end of dissectionphase to control metabolic disturbances during anhepaticphase and to maintain good internal environment before theliver graft anastomosis. Higher blood pressure should bemaintained to ensure the perfusion of transplanted kidney.Timing to procure donor kidney should be at the end ofhepatic artery anastomosis.

Post-transplant a nonnephrotoxic immunosuppressiveregimen or a regimen with low nephrotoxic potentialshould preferably be used [10].

CONCLUSION

Anesthesia considerations for liver transplantationinclude the management of severely deranged physiology,pharmacology, and biochemistry, as all organ systems maybe affected adversely by the failing liver. A close workingrelationship between all members of the operating team isnecessary for the success of the program. Thedevelopment of such teams in major transplant centers hasresulted in a marked reduction in the morbidity andmortality of this procedure and a concomitant reduction inthe cost.

This case shows a good result of living donation fromdifferent donor and combined liver kidney transplantationin patient with cirrhosis of liver and kidney failure.

REFERENCES

1. Starzl TE, Iwatsuki S, Van Thiel DH, et al. Evolution ofliver transplantation. Hepatology 1982; 2: 614-636.

2. Margreiter R, Kramar R, Huber C, Steiner E,Niederwieser D, Judmaier G, W Vogel. Combined liverand kidney transplantation. Lancet 1984; 323: 1077-1078.

3. Gil-Vernet S, Prieto C, Grino JM, Leiva O, Castelao AM,.Algranati L. Combined liver-kidney transplantation:Transplantation Proceedings. 1992; 24:128-129.

4. Jeyarajah DR, Gonva TA, Testa G, Abbasoglu O,Goldstein R, Husberg BS, Levy MF, Klintmalm GB. Liverand kidney Transplantation for polycystic Disease.Transplantation 1998; 66: 529-532.

5. Rogers J, Bueno J, Shapiro R, Scantlebury V,Mazariegos G, Fung J, Reyes J. Results of Simultaneousand Sequential Pediatric Liver and KidneyTransplantation. Transplantation 2001; 72: 1666-1670.

6. Marujo WC, Barros MFA, Cury RA, Pacheco-Silva A,Sette H. Successful combined kidney-liver right lobetransplant from a living donor. Lancet 1999; 353: 641.

7. Gattoni A, Marotta F, Vangieri B, Pisani G, Cristiano F.Hepatorenal syndrome. La Clinica Terapeutica 2004;155: 375-389.

8. Campbell MS, Kotlyar DS, Brensinger CM, et al. Renalfunction after orthotopic liver transplantation is predictedby duration of pretransplantation creatinine elevation.Liver Transplantation 2005;11:1048-1055.

9. Eason J D, Gonwa T A, Davis C L, Sung R S, Gerber D,Bloom R D. Proceedings of Consensus Conference onSimultaneous Liver Kidney Transplantation (SLK).American Journal of Transplantation 2008; 8: 2243–2251.

10. Bäckman L, Morales JM: Is non-nephrotoxicimmunosupression a possibility. Transplantation 69: 27-30, 2000.

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