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

Abstract

Renal dysfunction is a common comorbidity in patients with liver failure and is a well-established predictor of both morbidity and mortality among patients awaiting liver transplantation. The etiology of renal failure in patients with cirrhosis can be functional, structural, or represent a combination of potentially reversible physiologic changes and permanent histologic damage. Diagnostic criteria for acute and chronic kidney disease have been established, but cirrhosis poses challenges for accurate assessment of renal function with conventional clinical methods such as serum creatinine and creatinine-based estimating equations. Renal biopsies can have an important role for defining permanent structural damage as part of the pre-transplant evaluation of patients with liver disease; however, coagulopathy, portal hypertension and ascites increase the risk of biopsy-associated complications in cirrhotic patients. While renal dysfunction due to hepatorenal physiology is potentially reversible after liver transplantation, simultaneous kidney liver transplantation and kidney after liver transplant can also improve outcomes in a subset of patients with irreversible renal injury.

Addition of Kidney Dysfunction Type to MELD-Na for the Prediction of Survival in Cirrhotic Patients Awaiting Liver Transplantation in Comparison with MELD 3.0 with Albumin

“…Our initial hypothesis is that, in patients awaiting LT, the absolute value of serum creatinine is more crucial for the prognosis than the type of kidney dysfunction. While kidney dysfunction undoubtedly contributes to the prognosis of patients awaiting LT, the severity of renal dysfunction does not show a direct correlation with prognosis [ 23 ]. In fact, when calculating the original MELD or MELD-Na, a ceiling value of 4.0 is implemented for serum creatinine when it exceeds this threshold [ 24 ].…”

Simultaneous liver-kidney transplantation: A single-center experience in Korea

“…Some studies indicated that its prevalence is 15%-20% in LT candidates. 10 The requirement to update MELD scores after the initial listing allows for allocation of a liver to those most in need.…”

Current Status of Simultaneous Liver‐Kidney Transplantation in the United States

“…Serum creatinine was included in the MELD scoring system because renal impairment is associated with a substantial increase in 30‐day mortality, especially if an LT candidate requires dialysis . Renal impairment is a common occurrence in patients with liver disease with some studies indicating a prevalence of 15%‐20% in LT candidates . While awaiting LT, a candidate’s MELD score must be updated at specific intervals dictated by the candidate’s listing status and the previous MELD score (OPTN policy 9.2).…”

“…(13,14) Renal impairment is a common occurrence in patients with liver disease with some studies indicating a prevalence of 15%-20% in LT candidates. (15) While awaiting LT, a candidate's MELD score must be updated at specific intervals dictated by the candidate's listing status and the previous MELD score (OPTN policy 9.2). The requirement to update MELD scores after the initial listing allows for the allocation of a liver to those most in need.…”