CHAPTER 60: Simultaneous Kidney–Multivisceral Transplantation

NOMENCLATURE/TERMINOLOGY^1,2

• Multivisceral transplant (MVT) graft includes

  • Small bowel

  • Pancreas

  • Stomach

  • Liver

• Modified multivisceral transplant (MMVT): transplantation of the MVT graft without the liver

• Types of intestinal transplantation: Intestine alone, MVT, and MMVT

• Renal graft is not typically included within the standard MVT graft

• Simultaneous kidney–MVT: MVT and kidney transplantation occurring at the same time

BACKGROUND: SIMULTANEOUS KIDNEY–MVT

• Intestinal failure (IF) can occur both in adults and children secondary to a variety of causes.^1,3

• IF results in dependence on parenteral nutrition (PN).⁴

• Long-term PN may become impossible to maintain due to treatment complications.

• Intestinal transplant is an option to treat IF when PN cannot be maintained or for certain small bowel–related malignancy types.^1,3,4

• In a single-center study of 100 MVTs and MMVTs, renal failure was present in 25% of adult patients at the time of surgery.⁵

• Patients with renal failure at the time of MVT or MMVT have worse posttransplant outcomes.⁵

• Between 2000 and 2015, only 5% of the 2215 intestinal transplants performed in the United States included a simultaneous kidney transplant.⁶

  • 32.4% pediatrics vs. 67.6% adults

• Organ Procurement and Transplantation Network data (Jan. 1988–Aug. 2020)⁷

  • 114 liver–kidney–intestine–pancreas transplants

  • 8 kidney–intestine–pancreas transplants

  • 4 liver–kidney–intestine transplants

SPECIFIC INDICATIONS FOR MVT^3–5

• IF with cirrhosis or severe PN-induced liver injury/failure

• Significant portomesenteric thrombosis

• Frozen abdomen

• Certain tumors involving the liver and small bowel/mesenteric structures

SPECIFIC INDICATIONS FOR MMVTs^3–5

• IF and gastroparesis

• Pancreatitis complicated by mesenteric thrombosis

• Tumors involving the small bowel but sparing the liver

WHEN TO CONSIDER A SIMULTANEOUS KIDNEY–MVT

• When indications for both kidney transplant and MVT are met

• Loss of vascular access pre-MVT and marginal renal function⁶

  • Pretransplant glomerular filtration rate (GFR) <60 mL/min linked to >40% increased risk for mortality posttransplant⁸

  • Pretransplant acute kidney injury (AKI) is associated with a significant reduction in post-MVT long-term survival⁵

• Guidelines are not concretely defined given the infrequency of this procedure

  • Case-by-case analysis/discussion is necessary

  • MVT recipients can be listed for kidney transplant with GFR >20 mL/min per United Network for Organ Sharing (UNOS) guidelines⁶

RENAL FAILURE AND MVT

• Renal failure at time of MVT or MMVT confers worse posttransplant survival, especially in older patients⁵

• ~25% of adult intestinal transplant recipients develop end-stage-renal disease (ESRD), requiring dialysis or kidney transplantation⁹

• Dialysis after transplantation is associated with significantly worse outcomes⁹

• Risk factors:

  • Baseline diabetes mellitus

  • Baseline hypertension

  • MVT > intestinal transplantation without liver

• Possible contributing factors^5,6,9

  • Nephrotoxicity related to posttransplant immunosuppression

  • High risk for sepsis leading to acute tubular necrosis

  • Use of nephrotoxic antibiotics (aminoglycosides, etc.)

  • Challenging volume and electrolyte management pretransplant in setting of IF

OUTCOMES OF SIMULTANEOUS KIDNEY–MVT/MMVT/INTESTINE ALONE (U.S. DATA 2000–2015)⁶