title: Incidence and impact of rejection following simultaneous liver-kidney transplantation.
abstract: OBJECTIVE
  Due to hepatic immunoregulation, simultaneous liver-kidney recipients are presumed to be reasonably protected from kidney rejection and typically receive less immunosuppression compared to kidney transplants alone. However, data to support these conclusions and practices are sparse.
  
  
  METHODS
  We characterized the incidence and types of rejection, graft function, and graft and patient survival in a large population of simultaneous liver-kidney recipients (n=140) with long-term follow-up at our centre (1998-2010).
  
  
  RESULTS
  Acute cellular, antibody-mediated, and chronic kidney rejection was diagnosed in 9 (6.4%), 2 (1.4%), and 1 (0.7%) patient, respectively. Borderline acute kidney rejection was diagnosed in another 16 patients (11.4%). Acute cellular liver rejection occurred in 16 (11.4%) and chronic liver rejection in 4 (2.9%). One-, three-, and five-year patient survival was 86.4%, 78.0%, and 74.0%, respectively, and did not significantly differ by presence or absence of kidney or liver rejection. However, kidney rejection was associated with decreased renal function by lower serum GFR over time (p=0.003).
  
  
  CONCLUSIONS
  Various forms of kidney rejection occurred in ∼20% of our simultaneous liver-kidney recipients and were associated with deterioration in graft function, indicating that the liver may not confer complete protective allo-immunity. More stringent graft monitoring and management strategies, perhaps more akin to kidney transplant alone, should be prospectively studied in simultaneous liver-kidney recipients.
authors.affiliation: Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Kathy M
authors.initials: KM
authors.lastname: Nilles
authors.affiliation: Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: James
authors.initials: J
authors.lastname: Krupp
authors.affiliation: Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Brittany
authors.initials: B
authors.lastname: Lapin
authors.affiliation: Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Nedjema
authors.initials: N
authors.lastname: Sustento-Reodica
authors.affiliation: Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. Electronic address: l-gallon@northwestern.edu.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Gallon
authors.affiliation: Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. Electronic address: j-levitsky@northwestern.edu.
authors.forename: Josh
authors.initials: J
authors.lastname: Levitsky
mesh_terms: D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000453:epidemiology* / Q000517:prevention & control; D006085:Graft Survival; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D015994:Incidence; D016030:Kidney Transplantation; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011379:Prognosis; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology
chemical_list: D007166:Immunosuppressive Agents
keywords: Graft failure; Immunosuppression; Kidney transplantation; Liver transplantation; Outcomes; Rejection