Kidney Allocation to Liver Transplant Candidates with Renal Failure of Undetermined Etiology: Role of Percutaneous Renal Biopsy

Abstract

The feasibility, value and risk of percutaneous renal biopsy (PRB) in liver transplant candidates with renal failure are unknown. PRB was performed on 44 liver transplant candidates with renal failure of undetermined etiology and glomerular filtration rate (GFR) <40 mL/min/1.73 m 2 (n = 37) or on renal replacement therapy (RRT) (n = 7). Patients with ≥30% interstitial fibrosis (IF), ≥40% global glomerulosclerosis (gGS) and/or diffuse glomerulonephritis were approved for simultaneous-liver-kidney (SLK) transplantation. Prebiopsy GFR, urinary sodium indices, dependency on RRT and kidney size were comparable between 27 livertransplant-alone (LTA) and 17 SLK candidates and did not relate to the biopsy diagnosis. The interobserver agreement for the degree of IF or gGS was moderateto-excellent. After a mean of 78 ± 67 days, 16 and 8 patients received LTA and SLK transplants. All five LTA recipients on RRT recovered kidney function after transplantation and serum creatinine was comparable between LTA and SLK recipients at last followup. Biopsy complications developed in 13, of these, five required intervention. PRB is feasible in liver transplant candidates with renal failure and provides reproducible histological information that does not relate to the pretransplant clinical data. Randomized studies are needed to determine if PRB can direct kidney allocation in this challenging group of liver transplant candidates.

Renal Dysfunction in Liver Transplant Candidates: Evaluation, Classification and Management in Contemporary Practice

“…In one study, prevalence of proteinuria and hematuria was higher in patients with membranoproliferative glomerulonephritis than in patients with minimal findings or predominant histological diagnosis of acute tubular necrosis, interstitial fibrosis or glomerulosclerosis, but there was no correlation of proteinuria or hematuria with the degree of renal damage in patients with liver disease. The prevalence of hematuria and proteinuria was similar when transplant candidates accepted for liver transplant alone where compared to those with extensive interstitial fibrosis, glomerulosclerosis and/or diffuse membranoproliferative glomerulonephritis recommended for SLK [42]. In addition, the absence of proteinuria and hematuria do not exclude glomerular changes [42,43].…”

“…The prevalence of hematuria and proteinuria was similar when transplant candidates accepted for liver transplant alone where compared to those with extensive interstitial fibrosis, glomerulosclerosis and/or diffuse membranoproliferative glomerulonephritis recommended for SLK [42]. In addition, the absence of proteinuria and hematuria do not exclude glomerular changes [42,43].…”

“…In a series of 44 patients with cirrhosis, Wadei et al [42] described a 30% percutaneous biopsy complication rate with 11% requiring fluoroscopic guided embolization. There were no surgical interventions or deaths associated with this procedure.…”

“…Because renal biopsy has been shown to be safe and effective in patients with liver failure, it has been utilized for SLK transplant evaluation in some centers [42,75] and recommended by the UNOS guidelines for dual listing. In a study by Tanriover et al [75], patients with prolonged renal dysfunction, as estimated by serum creatinine and confirmed by direct measurement of the GFR using the iodine-125 iothalamate test, was recommended for renal biopsy.…”

“…Followup results confirmed acceptable outcomes in kidney function for those patients with favorable renal biopsy findings despite significant clinical renal dysfunction who underwent liver transplant alone. Wadei et al [42], retrospectively analyzed the outcomes of 44 liver transplant candidates with impaired renal function of unknown origin that underwent a percutaneous native kidney biopsy. A decision to proceed with SLK transplant was made if the biopsy showed >40% global glomerulosclerosis, >30% interstitial fibrosis, and/or diffuse (involving 50% of glomeruli) membranoproliferative glomerulonephritis (MPGN).…”