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With the increase in patients having impaired renal function at liver transplant due to MELD, accurate predictors of posttransplant native renal recovery are needed to select candidates for simultaneous liverkidney transplantation (SLK). Current UNOS guidelines rely on specific clinical criteria for SLK allocation. To examine these guidelines and other variables predicting nonrecovery, we analyzed 155 SLK recipients, focusing on a subset (n = 78) that had post-SLK native GFR (nGFR) determined by radionuclide renal scans. The 77 patients not having renal scans received a higher number of extended criteria donor organs and had worse posttransplant survival. Of the 78 renal scan patients, 31 met and 47 did not meet pre-SLK UNOS criteria. The UNOS criteria were more predictive than our institutional criteria for all nGFR recovery thresholds (20-40 mL/min), although at the most conservative cut-off (nGFR ≤ 20) it had low sensitivity (55.3%), specificity (75%), PPV (67.6%) and NPV (63.8%) for predicting post-SLK nonrecovery. On multivariate analysis, the only predictor of native renal nonrecovery (nGFR ≤ 20) was abnormal pre-SLK renal imaging (OR 3.85, CI 1.22-12.5). Our data support the need to refine SLK selection utilizing more definitive biomarkers and predictors of native renal recovery than current clinical criteria.

Biomarkers predictive of recovery from acute kidney injury (AKI) after liver transplantation (LT) could enhance decision algorithms regarding the need for liver-kidney transplantation or renal sparing regimens. Multianalyte plasma/urine kidney injury protein panels were performed immediately before and 1 month post-LT in an initial test group divided by reversible pre-LT AKI (rAKI 5 post-LT renal recovery) versus no AKI (nAKI). This was followed by a larger validation set that included an additional group: irreversible pre-LT AKI (iAKI 5 no post-LT renal recovery). In the test group (n 5 16), six pre-LT plasma (not urine) kidney injury proteins (osteopontin [OPN], neutrophil gelatinase-associated lipocalin, cystatin C, trefoil factor 3, tissue inhibitor of metalloproteinase [TIMP]-1, and b-2-microglobulin) were higher in rAKI versus nAKI (P < 0.05) and returned to normal values with renal recovery post-LT. In the validation set (n 5 46), a number of proteins were significantly higher in both rAKI and iAKI versus nAKI. However, only pre-LT plasma OPN (P 5 0.009) and TIMP-1 (P 5 0.019) levels were significantly higher in rAKI versus iAKI. Logistic regression modeling was used to correlate the probability of post-LT rAKI, factoring in both pre-LT protein markers and clinical variables. A combined model including elevated OPN and TIMP-1 levels, age <57, and absence of diabetes had the highest area under the curve of 0.82, compared to protein-only and clinical variable-only models. Conclusion: These data suggest that plasma protein profiles might improve the prediction of pre-LT kidney injury recovery after LT. However, multicenter, prospective studies are needed to validate these findings and ultimately test the value of such protein panels in perioperative management and decision making. (HEPATOLOGY 2014;60:2017-2026 A high percentage of patients with decompensated liver failure have renal dysfunction which directly correlates with survival outcomes. Given the weight of serum creatinine in the Model for End-Stage Liver Disease (MELD) calculation, the majority of patients receiving liver transplantation (LT) have renal impairment that may or may not be reversible postoperatively. 1 It is well known that LT recipients with kidney injury, particularly those who require renal replacement therapy (RRT), have worse survival. [2][3][4]

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The objective of this study was to examine associations of blood pressure (BP) with ratios of overnight to 24-h urinary excretion of sodium, potassium, and water. Each of 125 men 27-64 years of age, not taking diuretics, had BP measured during the day on a Monday. Beginning Monday evening, each participant provided three carefully timed 24-h urine collections, divided into daytime and overnight (bedtime to awakening) specimens. Proportion of total 24-h excretion of sodium, potassium, and water in the overnight specimen, standardised for creatinine excretion, was determined for each 24-h period. Associations of systolic and diastolic BP (SBP/DBP) with these proportions were examined with control for age, body mass index, alcohol intake, and heart rate. Mean BP was 116/71 mm Hg; 15 men were on non-diuretic anti-hypertensive therapy. Mean 24-h urinary excretion was 168 mmol for sodium, 68 mmol for potassium, and 16 mmol for creatinine. Mean overnight