Combined Solid Organ Transplantation Involving the Liver

  • Geraldine C. DiazEmail author
  • Jarva Chow
  • John F. Renz


Transplantation of the liver (LTX) in combination with other solid organs, both abdominal and thoracic, has significantly increased over the past decade (Fig. 19.1) [1]. This is the result of many factors including improved medical management of patients with end-stage liver disease (ESLD), advances in thoracic organ transplantation and a Model for End-stage Liver Disease (MELD)-based liver allocation policy [2, 3, 4]. The introduction of prophylactic beta-blockers to decrease portal hypertension, widespread application of endoscopic modalities to treat esophageal varices, availability of TIPS (transjugular intrahepatic portosytemic shunt) procedures and effective medications to control hepatitis B and hepatitis C viral replication have significantly increased the life expectancy of patients with ESLD [2]. Improved life expectancy results in additional organ-system failures in some that are potentially amenable to transplantation. Furthermore, improved outcomes of...


Liver–kidney transplantation Renal transplantation Heart–liver transplantation Lung–liver transplantation Intraoperative management Renal failure 


  1. 1.
    SRTR. United Network for Organ Sharing. In: Scientific Registry of Transplant Recipients; 2016.Google Scholar
  2. 2.
    Ge P, Runyon B. Treatment of patients with cirrhosis. NEJM. 2016;375:767–77.CrossRefGoogle Scholar
  3. 3.
    Hoechter D, von Dossow V. Lung transplantation: from the procedure to managing patients with lung transplant. Curr Opin Anaesthesiol. 2016;29:8–13.CrossRefGoogle Scholar
  4. 4.
    Wiesner R, McDiarmid S, Kamath P, et al. MELD and PELD: application of survival models to liver allocation. Liver Transpl. 2001;7:567–80.CrossRefGoogle Scholar
  5. 5.
    Gonwa T, McBride M, Anderson K, Mai M, Wadei H, Ahsan N. Continued influence of preoperative renal function on outcome of orthotopic liver transplant in the US: where will MELD lead us? Am J Transplant. 2006;6:2651–9.CrossRefGoogle Scholar
  6. 6.
    Margreiter R, Kramar R, Huber C, et al. Combined liver and kidney transplantation. Lancet. 1984;1:1077–8.CrossRefGoogle Scholar
  7. 7.
    Eason J, Gonwa T, Davis C, Sung R, Gerber D, Bloom R. Proceedings of consensus conference on simultaneous liver kidney transplantation (SLK). Am J Transplant. 2008;8:2243–51.CrossRefGoogle Scholar
  8. 8.
    Puri V, Eason J. Simultaneous liver–kidney transplantation. Curr Transpl Rep. 2015;2:297–302.CrossRefGoogle Scholar
  9. 9.
    Formica R, Aeder M, Boyle G, et al. Simultaneous liver–kidney allocation policy: a proposal to optimize appropriate utilization of scarce resources. Am J Transplant. 2016;16:758–66.CrossRefGoogle Scholar
  10. 10.
    Fong T, Khemichiam S, Shah T, Hutchinson I, Cho Y. Combined liver–kidney transplantation is preferable to liver transplant alone for cirrhotic patients with renal failure. Transplantation. 2012;94:411–6.CrossRefGoogle Scholar
  11. 11.
    Bellomo R, Ronco C, Kellum J, Mehta R, Palevsy P, ADQI Workgroup. Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004;8:R204–R12.CrossRefGoogle Scholar
  12. 12.
    Kellum J, Mehta R, Angus D, Palevsky P, Ronco C. The first international censensus conference of continuous renal replacement therapy. Kidney Int. 2002;62:1855–63.CrossRefGoogle Scholar
  13. 13.
    Modi R, Patel N, Metwally S, Mumtaz K. Outcomes of liver transplantation in patients with hepatorenal syndrome. World J Hepatol. 2016;8:999–1011.CrossRefGoogle Scholar
  14. 14.
    Gines A, Escorsell A, Gines P, et al. Incidence, predictive factors, and prognosis of hepatorenal syndrome in cirrhosis. Gastroenterology. 1993;105:229–36.CrossRefGoogle Scholar
  15. 15.
    Arroyo V, Gines P, Gerbes A, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. Hepatology. 1996;23:164–76.CrossRefGoogle Scholar
  16. 16.
    Salerno F, Gerbes A, Gines P, Wong F, Arroyo V. Diagnosis, prevention, and treatment of hepatorenal syndrome in cirrhosis. Gut. 2007;56:1310–8.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Papafragkakis H, Martin P, Akalin E. Combined liver and kidney transplantation. Curr Opin Organ Transplant. 2010;15:263–8.CrossRefGoogle Scholar
  18. 18.
    Angeli P, Gines P, Wong F, et al. Diagosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. Gut. 2015;64:531–7.CrossRefGoogle Scholar
  19. 19.
    Mehta R, Kellum J, Shah S, et al. Acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11:R31.CrossRefGoogle Scholar
  20. 20.
    Cholongitas E, Calvaruso V, Senzolo M, et al. RIFLE classification as predictive factor of mortality in patients with cirrhosis admitted to intensive care unit. J Gastroenterol Hepatol. 2009;24:1639–47.CrossRefGoogle Scholar
  21. 21.
    du Cheyron D, Bouchet B, Parienti J, Ramakers M, Charbonneau P. The attributable mortality of acute renal failure in critically ill patients with liver cirrhosis. Intensive Care Med. 2005;31:1693–9.CrossRefGoogle Scholar
  22. 22.
    O'Riordan A, Wong V, McQuillan R, McCormick P, Hegarty J, Watson A. Acute renal disease, as defined by the RIFLE criteria, post-liver transplantation. Am J Transplant. 2007;7:168–76.CrossRefGoogle Scholar
  23. 23.
    Wong F, Nadim M, Kellum J, et al. Working party proposal for a revised classification system of renal dysfunction in patients with cirrhosis. Gut. 2011;60:702–9.CrossRefGoogle Scholar
  24. 24.
    Davis C, Feng S, Sung R, et al. Simultaneous liver-kidney transplantation: evaluation to decision making. Am J Transplant. 2007;7:1702–9.CrossRefGoogle Scholar
  25. 25.
    Nadim M, Sung R, Davis C, et al. Simultaneous liver–kidney transplantation summit: current state and future directions. Am J Transplant. 2012;12:2901–8.CrossRefGoogle Scholar
  26. 26.
    De Deken J, Kocabayoglu P, Moers C. Hypothermic machine preservation in kidney transplantation. Curr Opin Organ Transplant. 2016;21:294–300.CrossRefGoogle Scholar
  27. 27.
    Sladen R. Anesthetic concerns for the patient with renal or hepatic disease. ASA Refresher Courses in Anesthesiology. 2001;29:213–28.CrossRefGoogle Scholar
  28. 28.
    Arnal D, Garutti I, Perez-Pena J, Olmedilla L, Tzenkiv I. Radial to femoral arterial blood pressure differences during liver transplantation. Anaesthesia. 2005;60:766–71.CrossRefGoogle Scholar
  29. 29.
    Krenn C, De Wolf A. Current approach to intraoperative monitoring in liver transplantation. Curr Opin Organ Transplant. 2008;13:285–90.CrossRefGoogle Scholar
  30. 30.
    Soong W, Sherwani S, Ault M, Baudo A, Herborn J, De Wolf A. United States practice patterns in the use of transesophageal echocardiography during adult liver transplantation. J Cardiothorac Vasc Anesth. 2014;28:635–9.CrossRefGoogle Scholar
  31. 31.
    Rudnick M, Marchi L, Plotkin J. Hemodynamic monitoring during liver transplantation: a state of the art review. World J Hepatol. 2015;7:1302–11.CrossRefGoogle Scholar
  32. 32.
    Sprung J, Kapural L, Bourke D, O'Hara J. Anesthesia for kidney transplant surgery. Anesthesiol Clin North America. 2000;18:919–51.CrossRefGoogle Scholar
  33. 33.
    Agopian V, Dhillon A, Baber J, et al. Liver transplantation in recipients receiving renal replacement therapy: outcomes analysis and the role of intra-operative hemodialysis. Am J Transplant. 2014;14:1638–47.CrossRefGoogle Scholar
  34. 34.
    Kang Y. Transfusion based on clinical coagulation monitoring does reduce hemorrhage during liver transplantation. Liver Transpl Surg. 1997;3:655–9.CrossRefGoogle Scholar
  35. 35.
    Mallet S. Clinical utility of viscoelastic tests of coagulation (TEG/ROTEM) in patients with liver disease and during liver transplantation. Semin Thromb Hemost. 2015;41:527–37.CrossRefGoogle Scholar
  36. 36.
    Lemmens H. Kidney transplantation: recent developments and recommendations for anesthetic management. Anesthesiol Clin North America. 2004;22:651–62.CrossRefGoogle Scholar
  37. 37.
    Faenza S, Arpesella G, Bernardi E, et al. Combined liver transplants: main characteristics from the standpoint of anesthesia and support in intensive care. Transplant Proc. 2006;38:1114–7.CrossRefGoogle Scholar
  38. 38.
    Shaw B, Stratta R, Donovan J, Langnas A, Wood R, Markin R. Postoperative care after liver transplantation. Semin Liver Dis. 1989;9:202–30.CrossRefGoogle Scholar
  39. 39.
    Starzl T, Bahnson H, Hardesty R, et al. Heart–liver transplantation in a patient with familial hypercholesterolaemia. The Lancet. 1984;323:1382–3.CrossRefGoogle Scholar
  40. 40.
    Olivieri N, Liu P, Sher G, et al. Brief report: combined liver and heart transplantation for end-stage iron-induced organ failure in an adult with homozygous beta-thalassemia. N Engl J Med. 1994;330:1125–7.CrossRefGoogle Scholar
  41. 41.
    Surakomol S, Olson L, Rastogi A, et al. Combined orthotopic heart and liver transplantation for genetic hemochromatosis. J Heart Lung Transplant. 1997;16:573–5.PubMedGoogle Scholar
  42. 42.
    Pilato E, Dell’Amore A, Botta L, Arpesella G. Combined heart and liver transplantation for familial amyloidotic neuropathy. Eur J Cardiothorac Surg. 2007;32:180–2.CrossRefGoogle Scholar
  43. 43.
    DiStefano Y, Cvetkovic D, Malekan R, McGoldrick K. Anesthetic management of combined heart-liver transplantation in a patient with ischemic cardiomyopathy and cardiac cirrhosis: lessons learned. J Cardiothorac Vasc Anesth. 2016;31:646–52.CrossRefGoogle Scholar
  44. 44.
    Careddu L, Zanfi C, Pantaleo A, et al. Combined heart-liver transplantation: a single-center experience. Transpl Int. 2015;28:828–34.CrossRefGoogle Scholar
  45. 45.
    Cannon R, Hughes M, Jones C, Eng M, Marvin M. A review of the United States experience with combined heart-liver transplantation. Transpl Int. 2012;25:1223–8.CrossRefGoogle Scholar
  46. 46.
    Porrett P, Desai S, Timmins K, Twomey C, Sonnad S, Olthoff K. Combined orthotopic heart and liver transplantation: the need for exception status listing. Liver Transpl. 2004;10:1539–44.CrossRefGoogle Scholar
  47. 47.
    Diaz G, Renz J, Nishanian E, Kinkhabwala M, Emond J, Wagener G. Anesthetic management of combined heart-liver translantation. J Cardiothorac Vasc Anesth. 2007;21:253–6.CrossRefGoogle Scholar
  48. 48.
    Nagpal A, Chamogeorgakis T, Shafii A, et al. Combined heart and liver transplantation: the Cleveland Clinic experience. Ann Thorac Surg. 2013;95:179–82.CrossRefGoogle Scholar
  49. 49.
    Offstad J, Schrumpf E, Geiran O, Soreide O, Simonsen S. Plasma exchange and heart-liver transplantation in a patient with homozygous familial hypercholesterolemia. Clin Transplant. 2001;15(6):432.CrossRefGoogle Scholar
  50. 50.
    Pirenne J, Verleden G, Nevens F, et al. Combined liver and (heart-) lung transplantation in liver transplant candidates with refractory portopulmonary hypertension. Transplantation. 2002;73:140–56.CrossRefGoogle Scholar
  51. 51.
    Shaw B, Bahnson H, Hardesty R, Griffith B, Starzl T. Combined transplantation of the heart and liver. Ann Surg. 1985;202:667–72.CrossRefGoogle Scholar
  52. 52.
    Barbara D, Rehfeldt K, Heimbach J, Rosen C, Daly R, Findlay J. Combined heart-liver transplantation experience and improved organ utilization. Ann Thorac Surg. 2015;99:1488–9.CrossRefGoogle Scholar
  53. 53.
    Hennessey T, Backman S, Cecere R, et al. Combined heart and liver transplantation on cardiopulmonary bypass: report of four cases. Can J Anesth. 2010;57:355–60.CrossRefGoogle Scholar
  54. 54.
    Baker J, Yost C, Niemann C. Organ transplantation. In: Miller R, editor. Miller’s anesthesia. Philadelphia: Elsevier; 2005. p. 2231–83.Google Scholar
  55. 55.
    Cheng D, Ong D. Anaesthesia for non-cardiac surgery in heart-transplanted patients. Can J Anesth. 1993;40:981–6.CrossRefGoogle Scholar
  56. 56.
    Steadman R. Anesthesia for liver transplant surgery. Anesthesiol Clin North America. 2004;22:687–711.CrossRefGoogle Scholar
  57. 57.
    Rossi G. Veno-venous bypass versus no bypass in orthotopic liver transplantation: hemodynamic, metabolic, and renal data. Transplant Proc. 1998;30:1871–3.CrossRefGoogle Scholar
  58. 58.
    Chuttani K, Tischler M, Pandian N, Lee R, Mohanty P. Diagnosis of cardiac tamponade after cardiac surgery: relative value of clinical, echocardiographic, and hemodynamic signs. Am Heart J. 1994;127:913–8.CrossRefGoogle Scholar
  59. 59.
    Eyraud D, Vaillant J, Ionescu C, et al. Early primary cardiac graft fialure and combined heart-liver transplantation: need for an uncommon doule bypass. Br J Anaesth. 2011;107:280–1.CrossRefGoogle Scholar
  60. 60.
    Fitzsimmons M, Ichinose F, Vagefi P, et al. Successful right ventricular mechanical support after combined heart-liver transplantation. J Cardiothorac Vasc Anesth. 2014;28:1583–5.CrossRefGoogle Scholar
  61. 61.
    Merlo C, Weiss E, Orens J, et al. Impact of U.S. lung alocation score on survival after lung transplantation. J Heart Lung Transplant. 2009;28:769–75.CrossRefGoogle Scholar
  62. 62.
    Barshes N, DiBardino D, McKenzie E, et al. Combined lung and liver transplantation: the United States experience. Clin Transplant. 2005;80:1161–7.CrossRefGoogle Scholar
  63. 63.
    Barshes N, Udell I, Joyce D, Southard R, O'Mahony C, Goss J. A pooled analysis of posttransplant survival following combined heart-liver transplantation. Transplantation. 2007;83:95–8.CrossRefGoogle Scholar
  64. 64.
    Couetil J, Houssin D, Soubrane O, et al. Combined lung and liver transplantation in patients with cystic fibrosis: a 4 1/2-year experience. J Thorac Cardiovasc Surg. 1995;110:1415–23.CrossRefGoogle Scholar
  65. 65.
    Yi S, Burroughs S, Loebe M, et al. Combined lung and liver transplantation: analysis of a single-center experience. Liver Transpl. 2013;20:46–53.CrossRefGoogle Scholar
  66. 66.
    Lenaerts C, Lapierre C, Patriquin H, et al. Surveillance for cystic fibrosis-associated hepatobiliary disease: early ultrasound changes and predisposing factors. J Pediatr. 2003;143:343–50.CrossRefGoogle Scholar
  67. 67.
    Feigelson J, Anagnostopoulos C, Poquet M, Pecau Y, Munck A, Navarro J. Liver cirrhosis in cystic fibrosis-therapeutic implications and long term follow up. Arch Dis Child. 1993;68:653–7.CrossRefGoogle Scholar
  68. 68.
    Castro M, Krowka M, Schroeder D, et al. Frequency and clinical implications of increased pulmonary artery pressures in liver transplant patients. Mayo Clin Proc. 1996;71:543–51.CrossRefGoogle Scholar
  69. 69.
    Ramsay M, Simpson B, Nguyen A, Ramsay K, East C, Klintmalm G. Severe pulmonary hypertension in liver transplant candidates. Liver Transpl Surg. 1997;3:494–500.CrossRefGoogle Scholar
  70. 70.
    Krowka M, Mandell M, Ramsay M, et al. Hepatopulmonary syndrome and portopulmonary hypertension: a report of the multicenter liver transplant database. Liver Transpl. 2004;10:174–82.CrossRefGoogle Scholar
  71. 71.
    Scouras N, Matsusaki T, Boucek C, et al. Portopulmonary hypertension as an indication for combined heart, lung, and liver or lung and liver transplantation: literature review and case presentation. Liver Transpl. 2011;17:137–43.CrossRefGoogle Scholar
  72. 72.
    Wallwork J, Williams R, Calne R. Transplantation of liver, heart, and lungs for primary biliary cirrhosis and primary pulmonary hypertension. Lancet. 1987;25:182–5.CrossRefGoogle Scholar
  73. 73.
    Slinger P. Anesthetic management for lung transplantation. Tx Med. 2012;24:27–34.Google Scholar
  74. 74.
    Zimmerman A, Howard T, Huddleston C. Combined lung and liver transplantation in a girl with cystic fibrosis. Can J Anesth. 1999;46:571–5.CrossRefGoogle Scholar
  75. 75.
    Benedetto M, Romano R, Bacha G. Inhaled nitric oxide in cardiac surgery: evidence or tradition? Nitric Oxide. 2015;49:67–79.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of AnesthesiologyUniversity of Illinois at ChicagoChicagoUSA
  2. 2.Department of AnesthesiologyLoyola UniversityChicagoUSA
  3. 3.Section of Transplantation, Department of SurgeryUniversity of ChicagoChicagoUSA

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