Combined liver-kidney transplantation in polycystic disease: Our experience and literature review

Abstract

Combined liver-kidney transplantation (CLKT) is lifesaving for patients with end-stage liver disease and underlying chronic kidney disease. Kidney injury is common, and CLKT accounts for 10% of all liver transplants, reflecting the physiological changes caused by portal hypertension in patients with end-stage liver disease. The increasing number of CLKT procedures has resulted in a large cohort of patients who should be studied in detail to identify factors (both donor- and recipient-related) that are associated with better outcomes. Evidence is emerging on the safety and efficacy of delaying the kidney component of CLKT and on the immunological benefits of multiorgan transplantation involving the liver. In this article, we review the most recent analyses and provide our perspectives on best practices in CLKT, integrating the literature with our single-centre retrospective series of 20 adult polycystic disease patients who underwent CLKT at the Department of Abdominal Center IRCCS ISMETT between 2008 and 2025. Simultaneous liver-kidney transplantation has been a major advance in the management of patients with dual-organ disease. The development of new modalities of organ preservation should be encouraged in order to optimise the identification and selection of patients for CLKT and to increase the use of extended criteria donors.

Keywords: Combined liver-kidney transplantation; Liver transplant; Hypothermic machine perfusion; Polycystic disease; End-stage renal disease; Chronic liver disease; Cirrhosis

Core Tip: Polycystic liver-kidney disease is a rare but debilitating condition requiring combined liver-kidney transplantation. This evidence review integrates contemporary data with our single-centre series (ISMETT, 2008-2025) of 20 combined liver-kidney transplantations for polycystic disease. The results show 95% patient survival (95% confidence interval: 86%-100%) at 1 year, 3 years, and 5 years after transplant and two kidney graft losses. We summarise actionable selection and technical considerations, such as symptom-driven liver listing, renal trajectory, and selective native nephrectomy, and emphasise innovations including liver-mediated immunoprotection and hypothermic machine perfusion, which enable delayed kidney implantation and the safer use of extended criteria donors.