Controversies in combined liver-kidney transplantation: indications and outcomes.

Controversy surrounds simultaneous transplantation of a kidney and a liver because the practice is increasing, and organs for transplant are limited. Not only do recipients of both organs use 2 rather than 1 organ, but the kidney in dual transplantation jumps to the front of a very long kidney wait-list. Furthermore, there is suspicion that some patients who undergo combined liver and kidney transplantation may have reversible renal failure. Likewise, inappropriate liver transplantation in those with end-stage renal disease is possible given the heavy weighting of kidney dysfunction in the calculation of the model for end-stage liver disease score. Thus, a better way to determine the recoverability of renal dysfunction in liver transplant candidates and the degree of liver disease in end-stage renal disease is needed. Standardized strategies for candidate evaluation, selection, and process review are also necessary to improve organ allocation in those with both liver and kidney disease. However, basic and clinical investigation will be needed before an optimal algorithm is possible.