Liver-kidney transplantation in the Model for Endstage Liver Disease era: is it overdone?

Simultaneous liver-kidney transplantation is increasing. This stimulates concern about unnecessary kidney transplantation (for acute kidney failure, hepatorenal syndrome) in liver transplant candidates.

Liver transplants are allocated by the Model for Endstage Liver Disease (MELD) score - a number heavily weighted by the serum creatinine. The serum creatinine value varies depending upon the laboratory where it is measured, is different between genders without a correction factor in MELD and is generally inaccurate as a marker of kidney function in liver failure. Criteria for dual transplantation vary between programs and there is no official oversight of the practice. Up to 6.5% of simultaneous transplant candidates on dialysis at listing discontinue dialysis before transplant. Furthermore, simultaneous liver-kidney transplant compared with liver transplant alone improves survival only for those liver candidates on dialysis at transplant.

It is time to review the allocation of kidney allografts to liver transplant candidates to avoid inappropriate transplantation. More complete investigation of kidney function following simultaneous liver-kidney transplantation is needed, in addition to improved methods to determine the recoverability of renal dysfunction in liver transplant candidates. Before an optimal algorithm is possible, however, basic and clinical investigation will be needed.