Die kombinierte und sequentielle Leber-Nieren-Transplantation

Zusammenfassung

Die kombinierte Leber-Nieren-Transplantation (CLKT) und die Nierentransplantation nach Lebertransplantation (KALT) haben sich inzwischen zu etablierten Verfahren bei Patienten mit terminaler Leber- und Niereninsuffizienz entwickelt, mit einer stetig steigenden Anzahl an Transplantationen in den letzten Jahren. Die häufigsten Indikationen zur CLKT bei Erwachsenen sind die familiäre Zystennierenerkrankung mit schwerer Leberbeteiligung und die Leberzirrhose unterschiedlicher Genese mit begleitender terminaler oder präterminaler Niereninsuffizienz infolge chronischer Glomerulonephritis oder diabetischer Nephropathie. Hauptindikation zur CLKT bei Kindern ist die primäre Hyperoxalurie Typ I. Die KALT wird derzeit noch am häufigsten aufgrund einer Kalzineurininhibitor-induzierten chronischen Nephrotoxizität durchgeführt, wenngleich sich dies aufgrund des sich etablierenden Konzepts einer nierenschonenden Langzeitimmunsuppression in Zukunft ändern dürfte. Im Vergleich zur KALT gestaltet sich die Indikationsstellung zur CLKT zumeist schwieriger, da standardisierte Kriterien fehlen. Die Indikation muss daher in enger Zusammenarbeit aller beteiligten Fachdisziplinen gestellt werden, um in Zeiten allgemeiner Organknappheit unnötige Doppeltransplantationen bei Patienten mit reversibler Nierenfunktionsstörung zu vermeiden. Beim hepatorenalen Syndrom sollte eine CLKT nur bei einer GFR unter 20 ml/min über mehr als 3 Monate oder einer mehr als 1-monatigen Dialysepflichtigkeit in Betracht gezogen werden. Protektive immunologische Effekte des Lebertransplantats für das Nierentransplantat sind vor allem bei der CLKT zu vermuten.

Abstract

Combined liver-kidney transplantations (CLKT) and kidney after liver transplantations (KALT) are established treatments for patients with end-stage hepatic and renal disease and the number of transplantations has continuously increased over the past few years. The most frequent indications for CLKT in adults are polycystic kidney disease with severe liver involvement and liver cirrhosis of different origins with concomitant chronic kidney failure due to chronic glomerulonephritis or diabetic nephropathy. In children, CLKT is most frequently required due to primary oxalosis type I. At present the main indication for KALT still is calcineurin inhibitor-induced chronic nephrotoxicity, emphasizing the need for a nephron-sparing long-term immunosuppression in liver transplant recipients. Compared to KALT, the indications for CLKT are not as well defined and the decision must therefore be made on a case-by-case basis by a multidisciplinary team of experienced clinicians to avoid unnecessary transplantations of both organs in patients with reversible kidney failure, given the scarcity of organs for transplantation worldwide. In hepatorenal syndrome CLKT should only be considered if the GFR is lower than 20 ml/min for more than three months or if the patient has been on renal replacement treatment for more than one month. In CLKT, there appears to be a certain immunological protection for the kidney transplant by the liver transplant.

Kombinierte Leber-Nieren-Transplantation - Sequentielle Leber-Nieren-Transplantation - Hepatorenales Syndrom - Primäre Hyperoxalurie Typ 1 - Polyzystische Nierenerkrankung - Kalzineurininhibitor-induzierte chronische Nephrotoxizität - Simultane Leber-Nierentransplantation

combined liver-kidney transplantation - kidney after liver transplantation - hepatorenal syndrome - primary oxalosis type I - polycystic kidney disease - calcineurin inhibitor-induced chronic nephrotoxicity - simultaneous liver-kidney transplantation

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