Simultaneous liver and kidney transplant : the risks, pros, and cons

Following three high-risk surgeries over a 17-hour duration, a private hospital in Gujarat has managed a simultaneous liver and kidney (SLK) transplant in a patient from Myanmar, with organs harvested from live donors, in what is possibly a first of its kind feat in the state. The 48-year old patient is due to be discharged on Wednesday, 15 days after the surgeries were conducted.
The procedure, conducted at Apollo Hospital at Bhat, Gandhinagar, on May 3, involved two teams and three operations — one for extracting the liver from one live donor (the husband of the recipient’s ser), second for extracting kidney from another live donor (the brother of the recipient’s wife) and third for transplanting both organs in the recipient. This was an extremely sensitive procedure involving precise timing and multi-disciplinary coordination among medical teams.
Dr Chirag Desai, gastroenterology surgeon at the hospital, who was part of the team that conducted the procedure, said that type-2 diabetes and high blood pressure over a prolonged period of time in the patient had resulted in kidney damage, causing chronic renal failure. The liver functioning, too, had been affected due to Hepatitis-C and diabetes, thus requiring a transplant of both organs.
However, according to Dr Desai, going for a kidney transplant with a damaged liver may result in complications and organ rejection. Similarly, liver transplant in a patient with damaged kidneys can affect graft acceptance or patient survival. Additionally transplant of either of the two organs can further damage the other organ. This means that the kidneys may suffer damage post liver transplant and vice-versa. Moreover, for a patient with both liver and kidney damage, “there is a short window of time”, may be a few weeks or a month, to enhance their survival prospects. Such patients at present are given supportive care, are led for transplant but “to survive till the point when the procedure actually takes place does not happen” in a majority of cases.
In the 48-year old’s case, Dr Manoj Gumber, nephrolog and kidney transplant physician, said that a patient with kidney damage could be kept on dialysis for 10 years but one with twin organ damage could not continue with prolonged dialysis.
According to Dr Gumber, keeping the right immunosuppression balance during the procedure is key because if it is low, organ grafts might be rejected and if high, it can trigger infections. “Follow-up too remains important because medicines have to be changed periodically to regulate immunosuppression,” he said .
Dr Desai shed more light on the procedure.
What is the incidence of liver and kidney damage in a single individual in the Indian context?
A damaged liver ultimately damaging kidneys is not uncommon with 10-20 per cent incidence but getting a cadaver in time or getting two live and fit donors in the family is difficult. On the other hand, damaged kidneys further damaging liver is not common but kidney damage can co-ex with liver damage with an incidence of two to five per cent.
What are the risks, pros and cons of a SLK transplant?
The risk to life for SLK transplants is three-fold compared to the usual liver or kidney transplant surgeries. At the same time, if successful, they are “10-times more” advantageous in terms of survival and faster recovery rate. Individually, both kidney and liver transplants need common drugs and dosage to prevent graft rejection besides ICU stay. Liver damage increases susceptibility and vulnerability to infections, which in turn adversely affect kidneys. A challenge with SLK world over is, however, getting both organs from donors at the same time, fulfilling all requisite transplant criteria. Additionally, taking organs from live donors also puts them at risk. Ideally, organs received from cadaver donations would be recommended with SOTTO and NOTTO guidelines provisioning for prioritising such simultaneous transplant donees. Further, SLK requires coordination of interdisciplinary medical teams and multispecialty care. Possible risks include rejection of organs, infection, bleeding or even thrombosis.
Dr Gumber clarified the complications involved.
What contraindications have to be taken care of ?
While there are no specific contraindications, the patient has to be fit enough to withstand a 17-hour surgery. There should not be any evidence of infection in the body, cardiac issues or cancerous cells. They are screened from head to toe and have to be certified individual specials. A surgery happens only when there is a green signal from all.
What’s the quality of life post-SLK transplant?
Care has to be exercised with regular exercise, diet, frequent follow-ups and life-long steroids and immunosuppressant drugs prescription. There has to be a periodic evaluation of dosage. Immunosuppressant drugs can go down over time, depending on the patient’s bodily response to the graft. The first 72 hours is crucial post operation as the patient undergoes the transplant under general anesthesia for several hours. The possibility of organ rejection is there throughout the lifetime of any donee. So compliance with a drug regime and vigilant doctors are very important.