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very few case reports of combined lung&#8211;kidney transplantation &#40;CLKT&#41; have been described in the literature and&#44; as far as we are aware&#44; none have described this procedure in patients with end-stage renal disease on dialysis&#46; We present the first case of CLKT successfully carried out on a dialysis patient in Spain&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Report</span><p id="par0010" class="elsevierStylePara elsevierViewall">The recipient was a 38-year-old male with cystic fibrosis &#40;CF&#41; who presented severe respiratory failure and end-stage renal disease&#46; The renal dysfunction was related to long-term aminoglycoside exposure&#46; He was dialysis-dependent and had been on hemodialysis for the previous three years&#46; Lung transplantation was proposed in this patient &#40;who was oxygen-dependent&#41; in September 2008 due to pulmonary hypertension&#44; frequent infections and multiple hospital admissions&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Preoperative blood tests showed the following results&#58; 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<span class="elsevierStyleItalic">Pseudomonas aeruginosa&#44; Stenotrophomona maltophilia&#44; Aspergillus fumigatus&#44; Candida albicans</span> and <span class="elsevierStyleItalic">Candida tropicalis&#46;</span> Cytomegalovirus &#40;CMV&#41; serology was negative&#46; The echocardiogram showed normal systolic function&#44; mild pulmonary hypertension &#40;mean pulmonary arterial pressure &#40;PAP&#41; of 47<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; mild tricuspid regurgitation and minimal aortic regurgitation&#46; Chest tomography revealed the presence of diffuse bilateral bronchiectases and alveolar lesions mainly affecting the upper lobes&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The donor was a 41-year-old woman with a history of chronic hypertension who suffered a brain hemorrhage&#46; Her last arterial blood gas showed the following values&#58; PaO<span class="elsevierStyleInf">2</span>&#61;534<span class="elsevierStyleHsp" style=""></span>mmHg with FiO<span class="elsevierStyleInf">2</span>&#61;100&#37; and positive end-expiratory pressure &#40;PEEP&#41; of 5<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46; Endotracheal aspirate cultures and CMV serology were negative&#46; The donor had remained in the intensive care unit &#40;ICU&#41; for 24<span class="elsevierStyleHsp" style=""></span>h&#44; and the explantation surgery proceeded without complications&#46; The lungs were preserved in Perfadex&#42; &#40;Vitrolife&#44; Sweden&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The recipient underwent hemodialysis immediately before surgery&#44; and was then admitted to ICU with intubation and FiO<span class="elsevierStyleInf">2</span>&#61;100&#37; and PEEP&#61;10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46; His hematocrit was 30&#37;&#44; creatinine 3&#46;6<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; Na 146<span class="elsevierStyleHsp" style=""></span>mEquiv&#46;&#47;l and K 5&#46;7<span class="elsevierStyleHsp" style=""></span>mEquiv&#46;&#47;l&#46; His blood gas values were as follows&#58; pH&#61;7&#46;35&#44; pO<span class="elsevierStyleInf">2</span>&#61;295<span class="elsevierStyleHsp" style=""></span>mmHg and pCO<span class="elsevierStyleInf">2</span>&#61;42<span class="elsevierStyleHsp" style=""></span>mmHg&#46; Noradrenaline &#40;0&#46;48<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&#41; and nitric oxide &#40;60<span class="elsevierStyleHsp" style=""></span>ppm&#41; were used for establishing hemodynamics in the following 48<span class="elsevierStyleHsp" style=""></span>h&#46; Immunosuppression was induced with basiliximab and maintained with tacrolimus &#40;blood levels 10<span class="elsevierStyleHsp" style=""></span>ng&#47;ml postoperatively and 7<span class="elsevierStyleHsp" style=""></span>ng&#47;ml at 6 months&#41;&#44; mycophenolate mofetil &#40;1500<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h post-surgery&#44; tapered to 4<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;ml in the maintenance phase&#41; and prednisone&#46; Corticoid levels were 30<span class="elsevierStyleHsp" style=""></span>mg&#47;day postoperatively and were gradually reduced to 15<span class="elsevierStyleHsp" style=""></span>mg&#47;day at 6 months and 10<span class="elsevierStyleHsp" style=""></span>mg&#47;day after one year&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Transverse thoracosternotomy was performed for sequential double lung transplantation&#44; followed by kidney transplant in the right iliac fossa using the standard technique&#46; The ischemia time was 2&#44; 4 and 7<span class="elsevierStyleHsp" style=""></span>h for the left lung&#44; right lung and kidney&#44; respectively&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was extubated 34<span class="elsevierStyleHsp" style=""></span>h after the intervention&#46; MRSA&#44; <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#44; <span class="elsevierStyleItalic">Pseudomonas mucoide</span>&#44; <span class="elsevierStyleItalic">Candida albicans</span> and <span class="elsevierStyleItalic">Candida tropicalis</span> were detected in the tracheal aspirates&#44; but the samples were negative for CMV&#46; Intravenous &#40;linezolid&#44; voriconazole&#44; trimetoprim-sulfametoxazole and piperacillin&#47;tazobactam&#41; and inhaled antibiotic treatment &#40;tobramycin and amphotericin lipid complex&#41; was instigated&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Progressive deterioration in respiratory function&#44; with CO<span class="elsevierStyleInf">2</span> retention&#44; resulted in reintubation on day 10 post-surgery&#46; Acute lung rejection was suspected and corticosteroids were administered for three days&#46; The patient presented anuria during the immediate postoperative period and required continuous venovenous hemodialysis for 25 days&#46; Renal Doppler ultrasound showed permeable blood vessels&#46; The first renal biopsy &#40;with a serum tacrolimus level of 13<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; showed mild interstitial fibrosis&#44; mild atherosclerosis&#44; moderate acute tubular necrosis&#44; absence of glomerular pathology and weakly positive for CD4 in the peritubular capillaries&#46; Renal function gradually recovered&#44; and the creatinine clearance was 42<span class="elsevierStyleHsp" style=""></span>ml&#47;min 2 months after surgery&#46; On day 50 post-surgery&#44; the patient presented abdominal pain associated with leukocytosis&#46; Acute cholecystitis was diagnosed and the patient underwent a cholecystectomy with peritoneal lavage&#44; after which an urgent laparotomy revealed the presence of a perforated gangrenous gall bladder&#44; with associated choleperitonitis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was discharged 80 days post-transplant&#44; with improvement in the spirometry and renal function &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A and B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Forty-two months after the DLKT&#44; the patient was asymptomatic and leading an active life&#46; The chest X-ray did not show any abnormal findings &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41; and the FEV1 was 3340<span class="elsevierStyleHsp" style=""></span>cc &#40;84&#46;5&#37;&#41;&#59; serum creatinine was 1&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; and the creatinine clearance 86<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">According to clinical guidelines for lung transplantation&#44; CF is the third most common indication for which this procedure is performed&#44; but the multisystem nature of the disorder poses additional difficulties in the selection of candidates&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> These patients often present chronic infections due to antibiotic-resistant microorganisms which remain in the airways and sinuses after the transplant&#59; in the context of immunosuppression&#44; this constitutes a source of possible lung infections&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Although nephropathy is rare in CF&#44; this disorder shows some abnormalities in renal function&#44; and various drugs are used in the treatment of CF and infections that may be nephrotoxic&#44; such as the aminoglycosides&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The first case of a double lung&#8211;kidney transplant was published in 1998 in a patient with pulmonary lymphangioleiomyomatosis and renal angiolipomas after a unilateral nephrectomy&#46; This patient had acceptable creatinine clearance&#44; so a possible postoperative deterioration in renal function could be avoided&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> No similar cases were subsequently published&#44; and although the <span class="elsevierStyleItalic">International Society of Heart and Lung Transplantation</span> database includes cases of patients treated with combined transplantation of a single lung&#8211;kidney&#44; there are no data on their preoperative renal function or postoperative survival&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Simultaneous solid organ transplant has been more common in recent years&#44; and attempts have been made in reviews of combined liver&#8211;kidney transplantation<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and combined heart&#8211;lung transplantation<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> to analyze the indications&#44; technical considerations and expected results&#46; Rana et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> recently published the description of a simultaneous combined heart&#8211;lung&#8211;kidney transplantation with satisfactory results&#44; and highlighted the results of a previous study&#44; in which the simultaneous transplantation of multiple organs from the same donor showed lower rejection rates than single organ transplantation&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">CLKT is a surgically viable intervention at present&#44; but postoperative patient management may be difficult&#44; given that the strict fluid restriction required to prevent pulmonary edema must be balanced with the need for abundant fluid intake for renal function&#46; Furthermore&#44; immunosuppressive treatment for lung transplantation must be optimized to reduce the nephrotoxic effects&#44; especially when anti-calcineurin drugs are used&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In our case&#44; the required dose of calcineurin inhibitors was reduced by using basiliximab for the induction phase and tacrolimus&#47;mycophenolate instead of cyclosporine&#47;azathioprine for the maintenance phase&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In conclusion&#44; CLKT may be indicated in patients who are candidates for lung transplantation with concomitant end-stage renal disease&#46; This procedure is surgically viable&#44; but perioperative patient management is complex&#46; To obtain good results&#44; CLKT should only be carried out in specially trained centers with adequate donor and recipient selection&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors do not have any conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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        0 => array:2 [
          "identificador" => "xres193977"
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          "titulo" => "Introduction"
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          "titulo" => "Case Report"
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        6 => array:2 [
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          "titulo" => "Discussion"
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    "fechaRecibido" => "2012-08-10"
    "fechaAceptado" => "2012-10-30"
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            0 => "Lung transplantation"
            1 => "Kidney transplantation"
            2 => "Combined transplantation"
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            0 => "Trasplante de pulm&#243;n"
            1 => "Trasplante de ri&#241;&#243;n"
            2 => "Trasplante combinado"
            3 => "Fibrosis qu&#237;stica"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Advanced kidney disease is usually considered an absolute contraindication for lung transplantation due to the difficult management of these patients in the post-operative period&#46; Combined lung&#8211;kidney transplantation&#44; however&#44; could offer an opportunity for selected patients with renal and pulmonary dysfunction&#46; This study summarizes the long-term success of a double transplantation in a 38-year-old male patient with cystic fibrosis who presented respiratory and kidney failure&#46; After a complicated post-operative period&#44; the patient currently lives completely independently 46<span class="elsevierStyleHsp" style=""></span>months after the operation and he enjoys excellent pulmonary and renal function&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La enfermedad renal avanzada suele considerarse una contraindicaci&#243;n absoluta para el trasplante de pulm&#243;n&#44; debido a la dificultad de manejo del paciente en el periodo postoperatorio&#44; pero un trasplante combinado de pulm&#243;n-ri&#241;&#243;n podr&#237;a ofrecer una oportunidad a algunos pacientes seleccionados con disfunci&#243;n pulmonar y renal&#46; En este trabajo se resume el &#233;xito a largo plazo de un doble trasplante en un paciente var&#243;n de 38<span class="elsevierStyleHsp" style=""></span>a&#241;os con fibrosis qu&#237;stica que presentaba tambi&#233;n insuficiencia respiratoria&#46; Tras un periodo postoperatorio complicado&#44; el paciente vive en la actualidad de manera completamente independiente 46<span class="elsevierStyleHsp" style=""></span>meses despu&#233;s de la operaci&#243;n y disfruta de una excelente funci&#243;n pulmonar y renal&#46;</p>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Borro JM&#44; et al&#46; &#201;xito a largo plazo de un trasplante combinado de pulm&#243;n-ri&#241;&#243;n en un paciente con fibrosis qu&#237;stica&#46; Arch Bronconeumol&#46; 2013&#59;49&#58;272-4&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Renal and lung function follow-up data after the double transplant&#46;</p>"
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                          "etal" => false
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                      "titulo" => "Combined lung and liver transplantation&#58; the United States experience"
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