Combined liver-kidney surgeries under fire

Combined liver-kidney surgeries under fire

By Andrew Conte and Luis Fabregas
TRIBUNE-REVIEW
Sunday, June 15, 2008

Nine U.S. transplant programs gave so many patients a kidney along with a liver transplant last year that they should be reviewed to see whether the recipients really needed both organs, based on the consensus recommendation of leading doctors.

Those centers gave more than 15 percent of liver recipients a kidney at the same time -- a threshold that doctors at a March 2006 conference first said should trigger a review.

That's because 95 percent of liver recipients with short-term kidney failure recover kidney function after receiving a liver, according to researchers at the University of Pennsylvania. Combined liver-kidney transplants subject those people who regain kidney function to an unneeded surgery and deprive someone on the kidney waiting list from getting the organ.

"People are concerned organs may be placed when they're not necessarily required," said Dr. Connie L. Davis, a liver specialist at the University of Washington. "You want to give (an organ) to people who need it and not to people who don't. You don't want the extra surgery, the extra risk and the extra expense."

Unnecessary organ transplants have been under scrutiny since the Tribune-Review reported in March that hundreds of patients each year undergo liver transplants when they don't need them.

Last year, U.S. hospitals performed 424 combined liver-kidney transplants, according to data collected by the United Network for Organ Sharing, the federally funded nonprofit that oversees transplant policy. But the agency does not track how many patients' own kidneys recovered after receiving a new one.

UNOS officials are expected to discuss the issue next month at a meeting of its Liver & Intestinal Organ Transplantation committee. The agency is considering rules for when to give a patient both organs at the same time.

"One wonders if they're all justified or if one could do with the liver alone," said Dr. K. Rajender Reddy, director of Hepatology at the University of Pennsylvania.

The problem is predicting which liver recipients will need a kidney. Programs vary widely: some rarely performing the dual transplants while others doing them routinely. Each program sets its own guidelines for when to perform a liver-kidney transplant, which requires separate procedures, cuts and doctors while the patient is under anesthesia.

Officials at Piedmont Hospital in Atlanta -- a program with a high percentage of liver-kidney transplants, at 21.5 percent last year -- said the percentage may be attributed to their willingness to treat sicker patients who tend to need both organs.

"It's difficult to know, for sure, going into a transplant whether a person's kidneys will come back or not," said Dr. Robert Merion, clinical transplant director at the Scientific Registry of Transplant Recipients, a federally funded nonprofit that tracks and analyzes transplant data. "People are doing the best they can. I don't think we have all of those answers yet."

The University of Pittsburgh Medical Center has performed just three liver-kidney transplants in the past decade, and none since 2002. UPMC officials declined to comment, but Dr. Thomas E. Starzl, a pioneer in the field of transplantation at UPMC, said such surgery is rarely necessary.

"It is wasteful and has been wasteful for years," Starzl said. "We showed that kidneys are recoverable years ago."

Chicago's Northwestern Memorial Hospital, meanwhile, performed 22 liver-kidney transplants last year -- accounting for nearly one-fifth of its liver recipients.

Doctors are doing what's best for the patient by giving the person a kidney if there's a chance their own organs will not recover, said Dr. Michael Abecassis, transplant chief at Northwestern.

"It's a total guess ... whether the kidneys will come back or not," he said. "We wouldn't put a kidney in someone who would have them come back. The problem is the ability to predict."

The number of liver-kidney transplants at Northwestern, he said, could be expected to decline as doctors get better at determining which patients will continue to have kidney failure after receiving a liver.

One yardstick doctors are developing is length of time on dialysis, a treatment that cleanses the blood of waste products that build up when kidneys stop working.

Opinions vary but at the 2006 gathering, sponsored by UNOS and other leading transplant agencies, doctors agreed that patients merited a liver-kidney transplant if they had been on dialysis longer than six weeks. UNOS hasn't adopted that as a rule and doctors at each center make their own determination. UNOS data does not show how many liver-kidney recipients at each center were on dialysis at transplant.

Northwestern has adopted the new consensus policy "as of a few weeks ago," and it now gives combined liver-kidney transplants only to those patients who have been on dialysis at least six weeks, Abecassis said.

"It will be interesting to see the outcome of the implementation of this policy," he said. "We are in agreement with having a policy, and this policy is as good as any in the absence of any concrete evidence."

Doctors at Penn rarely recommend a dual transplant unless the patient has been on dialysis longer than 12 weeks, Reddy said. At Cedars-Sinai Medical Center in Los Angeles, which last year gave a kidney to 16.4 percent of its liver patients, surgeons consider giving a kidney when dialysis has been required for a month or longer, said Dr. Steven D. Colquhoun, director of transplantation.

"We leave it to our kidney team to decide, which is completely independent from the liver team and presumed to be unbiased," Colquhoun said.

Nationwide, however, 30 percent of the liver-kidney recipients last year were not even on dialysis at the time of transplant, according to UNOS data.

While some dual transplant recipients might not really need a kidney, others could get both organs even though they do not have advanced symptoms of liver disease.

Patients on the liver waiting list are ranked by a score called MELD, for Model End-stage Liver Disease, which is based on three blood tests. One of the tests measures kidney function, and it alone could push someone near the top of the liver list even if the patient doesn't have chronic liver disease. With 76,203 people waiting for a kidney, the patient might be able to get the organ sooner if he or she takes it with a liver.

"There are times when the liver might not be that bad," said Davis, the University of Washington nephrologist. "There's cirrhosis, but not to the point they need a new liver. But, 'Gosh, if you're going to put a kidney in, give them a new liver at same time because they're going to get there eventually.'"

Merion said he does not know of any programs that would give a patient a liver just to get them a kidney, saying "nobody in their right mind would do that" because liver transplant surgery is riskier than kidney surgery.

Better data gathering and analysis is needed to figure out if these transplants are necessary, said Dr. Robert Osorio, a transplant surgeon at California Pacific Medical Center in San Francisco, where 21.7 percent of liver patients received a kidney.

"Let's look at those patients who have been transplanted and see if there are patients with two or three kidneys working," Osorio said. "It should be something that we do routinely."

Andrew Conte can be reached at andrewconte@tribweb.com or 412-320-7835. Luis Fabregas can be reached at lfabregas@tribweb.com or 412-320-7998.

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