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Simultaneous liver kidney transplantation and (bilateral) nephrectomy through a midline is feasible and safe in polycystic disease.

ABSTRACT: In Eurotransplant, 50% of simultaneous liver kidney transplantations (SLK) are performed for polycystic disease. Classically, liver and kidney are transplanted in two steps: liver through a subcostal incision, kidney through a separate oblique incision. Liver and kidney volume can make this 'two-step' procedure challenging, especially if simultaneous native nephrectomy is indicated. A 'one-step' SLK through a xiphopubic laparotomy might be a safe alternative, facilitating mobilization of the voluminous polycystic liver and native nephrectomy whilst offering access to iliac fossae for kidney transplantation. One-step SLK procedures for polycystic disease were introduced in 08/2013 at IKEM Prague (n = 6) and 11/2014 at University Hospitals Leuven (n = 6). Feasibility and safety of the one-step technique were investigated. We compared surgical data and outcomes obtained with the one-step technique to all consecutive two-step procedures performed for polycystic disease at the University Hospitals Leuven between 2008-2014 (n = 23). Median (interquartile range) are given. One-step SLK offered broad and adequate exposure for the hepatectomy, nephrectomies and transplantations, which were all uneventful. Morbidity, patient (100% vs 91%, p = 0.53) and graft survival (100% graft survival for liver and kidney in both groups) were comparable between one-step and two-step SLK. Liver cold ischaemia time was comparable [6.0 (4.4-7.6) vs. 7.1 (3.9-7.3), p = 0.077], kidney cold ischaemia time was shorter in one-step compared to two-step SLK [8.1 (6.4-9.3) vs. 11.7 (10.0-14.0), p<0.001)]. Total procedural time was also shorter in one-step compared to two-step SLK [6.8 (4.1-9.3) vs. 9.0 (8.7-10.1), p = 0.032], while all underwent bilateral (67%) or unilateral (33%) nephrectomy (compared to 0% and 52% in two-step SLK, respectively). In one-step SLK, 67% received a pre-emptive kidney transplant compared to 46% in two-step SLK. 5/12 two-step SLK became dialysis dependant after pre-transplant nephrectomy, the 4 dialysis-dependant patients with one-step SLK had not undergone pre-transplant nephrectomy. In conclusion, one-step SLK for polycystic disease is feasible and safe.

SUBMITTER: Jochmans I

PROVIDER: S-EPMC5357044 | biostudies-literature | 2017

REPOSITORIES: biostudies-literature

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Simultaneous liver kidney transplantation and (bilateral) nephrectomy through a midline is feasible and safe in polycystic disease.

Jochmans Ina I Monbaliu Diethard D Ceulemans Laurens J LJ Pirenne Jacques J Fronek Jiri J

PloS one 20170317 3

In Eurotransplant, 50% of simultaneous liver kidney transplantations (SLK) are performed for polycystic disease. Classically, liver and kidney are transplanted in two steps: liver through a subcostal incision, kidney through a separate oblique incision. Liver and kidney volume can make this 'two-step' procedure challenging, especially if simultaneous native nephrectomy is indicated. A 'one-step' SLK through a xiphopubic laparotomy might be a safe alternative, facilitating mobilization of the vol ...[more]

PMID: 28306734

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Project description:AIMS/HYPOTHESIS:The glucosuria induced by sodium-glucose cotransporter 2 (SGLT2) inhibition stimulates endogenous (hepatic) glucose production (EGP), blunting the decline in HbA1c. We hypothesised that, in response to glucosuria, a renal signal is generated and stimulates EGP. To examine the effect of acute administration of SGLT2 inhibitors on EGP, we studied non-diabetic individuals who had undergone renal transplant with and without removal of native kidneys. METHODS:This was a parallel, randomised, double-blind, placebo-controlled, single-centre study, designed to evaluate the effect of a single dose of dapagliflozin or placebo on EGP determined by stable-tracer technique. We recruited non-diabetic individuals who were 30-65 years old, with a BMI of 25-35 kg/m2 and stable body weight (±2 kg) over the preceding 3 months, and HbA1c <42 mmol/mol (6.0%). Participants had undergone renal transplant with and without removal of native kidneys and were on a stable dose of immunosuppressive medications. Participants received a single dose of dapagliflozin 10 mg or placebo on two separate days, at a 5- to 14-day interval, according to randomisation performed by our hospital pharmacy, which provided dapagliflozin and matching placebo, packaged in bulk bottles that were sequentially numbered. Both participants and investigators were blinded to group assignment. RESULTS:Twenty non-diabetic renal transplant patients (ten with residual native kidneys, ten with bilateral nephrectomy) participated in the study. Dapagliflozin induced greater glucosuria in individuals with residual native kidneys vs nephrectomised individuals (8.6?±?1.1 vs 5.5?±?0.5 g/6 h; p?=?0.02; data not shown). During the 6 h study period, plasma glucose decreased only slightly and similarly in both groups, with no difference compared with placebo (data not shown). Following administration of placebo, there was a progressive time-related decline in EGP that was similar in both nephrectomised individuals and individuals with residual native kidneys. Following dapagliflozin administration, EGP declined in both groups, but the differences between the decrement in EGP with dapagliflozin and placebo in the group with bilateral nephrectomy (??=?1.11?±?0.72 ?mol min-1 kg-1) was significantly lower (p?=?0.03) than in the residual native kidney group (??=?2.56?±?0.33 ?mol min-1 kg-1). In the population treated with dapagliflozin, urinary glucose excretion was correlated with EGP (r?=?0.34, p?<?0.05). Plasma insulin, C-peptide, glucagon, prehepatic insulin:glucagon ratio, lactate, alanine and pyruvate concentrations were similar following placebo and dapagliflozin treatment. ?-Hydroxybutyrate increased with dapagliflozin treatment in the residual native kidney group, while a small increase was observed only at 360 min in the nephrectomy group. Plasma adrenaline (epinephrine) did not change after dapagliflozin and placebo treatment in either group. Following dapagliflozin administration, plasma noradrenaline (norepinephrine) increased slightly in the residual native kidney group and decreased in the nephrectomy group. CONCLUSIONS/INTERPRETATION:In nephrectomised individuals, the hepatic compensatory response to acute SGLT2 inhibitor-induced glucosuria was attenuated, as compared with individuals with residual native kidneys, suggesting that SGLT2 inhibitor-mediated stimulation of hepatic glucose production via efferent renal nerves occurs in an attempt to compensate for the urinary glucose loss (i.e. a renal-hepatic axis). TRIAL REGISTRATION:ClinicalTrials.gov NCT03168295 FUNDING: This protocol was supported by Qatar National Research Fund (QNRF) Award No. NPRP 8-311-3-062 and NIH grant DK024092-38. Graphical abstract.

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Simultaneous liver kidney transplantation and (bilateral) nephrectomy through a midline is feasible and safe in polycystic disease.

Publications

Simultaneous liver kidney transplantation and (bilateral) nephrectomy through a midline is feasible and safe in polycystic disease.

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