From the Guidelines
Simultaneous lung-kidney transplantation is generally recommended over sequential kidney transplantation after lung transplantation due to better overall survival rates, reduced rejection episodes, and improved long-term kidney function. When considering the outcomes of kidney transplant after lung transplant versus simultaneous lung-kidney transplant, several factors come into play, including the patient's current lung function stability, degree of kidney dysfunction, overall health status, and donor availability. The immunosuppressive regimen for both approaches typically includes tacrolimus (target levels 8-12 ng/mL initially, then 5-8 ng/mL long-term), mycophenolate mofetil (1000-1500 mg twice daily), and prednisone (tapered to 5 mg daily maintenance) 1. Some key points to consider in this decision include:
- The potential benefits of shared immunologic tolerance between organs from the same donor in simultaneous transplantation, which may reduce rejection risk.
- The cumulative surgical risks and complications associated with sequential transplantation, including the need for a second major surgery and immunosuppression induction.
- The importance of evaluating patients with rapidly deteriorating kidney function following lung transplantation early for kidney transplantation, as pre-dialysis kidney transplantation generally yields better outcomes. However, it's essential to note that the provided evidence primarily focuses on combined liver-kidney transplantation, and direct comparisons to lung-kidney transplantation are limited 1. Despite this, the principles of minimizing surgical risks, optimizing immunosuppression, and considering the patient's overall health status can still be applied to the decision-making process for lung-kidney transplantation. In the absence of direct evidence, the recommendation for simultaneous lung-kidney transplantation is based on the general principles of solid organ transplantation and the potential benefits of reduced rejection risk and improved long-term function. Ultimately, the decision between simultaneous and sequential transplantation should be individualized, taking into account the unique needs and circumstances of each patient.
From the Research
Outcomes of Kidney Transplant After Lung Transplant
- The outcomes of kidney transplant after lung transplant versus simultaneous lung-kidney transplant are influenced by various factors, including the type of induction immunosuppression regimen used 2.
- A study found that there was no difference in patient survival or death-censored kidney allograft survival among kidney after lung transplant recipients who received depletional, non-depletional, or no induction immunosuppression regimen 2.
- Another study reported that kidney after lung transplant (KALT) is a safe option, with postoperative morbidity and renal graft function identical to those of kidney transplantation in non-lung-transplanted patients 3.
Comparison of Simultaneous Lung-Kidney Transplant and Kidney After Lung Transplant
- A retrospective cohort study compared the outcomes of simultaneous lung-kidney transplant (CKLT) and KALT, and found that the 30-day and 1-year survival rates were lower in CKLT recipients (75.6%) compared to KALT recipients (no deaths during follow-up) 3.
- The study also found that the rate of severe surgical complications was higher in CKLT recipients (60%) compared to KALT recipients (30%) 3.
- A review of immunosuppression strategies for simultaneous organ transplant recipients, including lung-kidney transplants, highlighted the challenges of balancing immunosuppression with immunologic risk and allograft damage from surgical complications 4.
Long-Term Outcomes of Kidney Transplant After Lung Transplant
- A single-center retrospective study reported excellent long-term survival and acceptable kidney and lung allograft function in patients who underwent late living related kidney transplant after lung transplant 5.
- Another study found that patients who underwent kidney transplant after lung transplant had increased survival times compared to those who remained on the waitlist 6.
- The study also reported that simultaneous lung-kidney transplants (SLuK) had poorer outcomes compared to conventional kidney after lung transplant (KAL), but recent improvements have made SLuK an option for patients with renal dysfunction 6.