Renal and Multiorgan Transplantation: Are Valuable Grafts Being Wasted?

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Background: Renal transplantation, either synchronously with or subsequent to another solid organ, remains unusual. The number of transplant units with the multidisciplinary infrastructure to provide this service coupled with patients with adequate cardio-respiratory reserve and suitable indications for this procedure remain rare. The paucity of suitable donor organs for transplantation with lengthening waiting times has heightened interest in the suitability of transplanting this valuable resource into complex patients as the perception remains that outcomes in this cohort of patients may be suboptimal compared to the general recipient population. We aimed to assess outcomes of kidney grafts as part of multiorgan transplant combinations either synchronously or at a later juncture. Methods: A retrospective analysis was made of a renal transplant database maintained at a single institution offering multiorgan transplantation over 7 years (2005- 2011). This included patient undergoing kidney in combination with other solid organs (liver, heart or lung transplantation (but excluding pancreas) either at the time or as a result of end stage renal failure (ESRF) subsequent to previous solid organ transplantation. Patient and graft survival were assessed as primary endpoints with biopsy proven acute rejection (BPAR) and glomerular filtration rate (eGFR) at 3 and 6 months to as a reliable measure of graft function assessed as secondary endpoints. Results: 19 renal transplants were performed during the study period (13 synchronously with another organ; 7 following previous transplant; median age 51 (range 25-65); 10M, 9F) This comprised: 15 liver/kidney, 3 heart/kidney, 2 lung/heart/kidney and 1 lung/kidney. The aetiology of ESRF included: Calcinuerin toxicity: 8, polycystic disease: 8, Diabetes mellitus: 1, reflux nephropathy: 1, IgA nephropathy 1. 1 year or latest graft and patient survival was 100% (compared to total figures of 93.4% and 97.7% respectively for the entire renal transplant programme; p< 001 and p=0.12 respectively, Fisher's exact test.) Transplant median eGFR at 3 and 6 months was 57.2ml/min (range 25.1-133.7) and 60.7ml/min (range 26.7-77.4) respectively. The BPAR rate in the combined group was 21 % (4/19) compared to 13% (85/658; p=0.14, Fisher's exact test) for the total group. Conclusion: Multiorgan transplantation appears to offer a valuable opportunity for normalisation of renal function with excellent patient and graft survival and renal function outcomes in our cohort of patients. This study is limited slightly by the heterogeneous nature of the kidney graft timings used (synchronous and delayed transplants) as well as the differences in associated organs transplanted, but the infrequent nature of this type of transplantation ensures that meaningful independent series are very difficult to collate to provide meaningful results. It is of interest that the BPAR appears higher in this group compared to the entire programme, although not statistically significant, in the combined transplant group. This doesn't correlate with previous reports of the potential immunoprotective effects of combination transplantation. In carefully selected cases with adequate physiological reserve, it appears as though either synchronous or sequential multiorgan transplantation can be associated with excellent patient and graft outcomes and function. This ensures equitable use of the scarce resource of deceased donor grafts.

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