Renal dysfunction in liver transplant recipients: Evaluation of the critical issues

Abstract

Major progress has been made in the field of liver transplantation since the first procedure was performed nearly 50 years ago. Despite these improvements, renal dysfunction before and after liver transplantation remains a major complicating factor associated with increased health care costs, morbidity, and mortality. Creatinine-based estimates of renal function are inaccurate in the setting of end-stage liver disease and often lead to underdiagnosis and late intervention. This issue is critical in that it is important to understand both the etiology and chronicity of renal dysfunction before liver transplantation because the treatment clearly varies, especially with respect to simultaneous liver-kidney (SLK) transplantation. Because of the scarcity of available grafts, identifying appropriate candidates for SLK transplantation is crucial. Hepatorenal syndrome is common in liver transplant candidates; however, other etiologies of renal dysfunction need to be considered. Renal dysfunction after liver transplantation is common and may have an acute or chronic presentation. Although calcineurin inhibitors (CNIs) have been associated with post-liver transplant nephrotoxicity, their role may be overestimated, and other contributing etiologies should remain in a clinician's differential diagnosis. Alternatives to CNIs have been evaluated; however, a safe immunosuppressive regimen that achieves the preservation of renal function in liver transplant recipients remains to be established. In this review of the literature, renal dysfunction in the setting of liver transplantation is evaluated, and the critical issues that are barriers to improved outcomes are highlighted. Liver Transpl 18:1290-1301, 2012. V C 2012 AASLD.Received January 11, 2012; accepted July 11, 2012.Since the first liver transplant in the early 1960s, great progress has been made in both the surgical and medical management of liver transplant recipients. Major strides have been made in overcoming obstacles such as acute and chronic rejection, and once dreaded infectious complications such as cytomegalovirus and hepatitis B infections are largely manageable. The associated surgical procedures have become almost routine at many centers because of advances in surgical techniques, organ preservation, and anesthetic management. What most significantly affects the long-term outcomes of liver transplant recipients are the medical complications of liver transplantation, which include recurrent hepatitis C, 1 diabetes mellitus, 2 malignancies, 3 and renal dysfunction. 4The development of renal dysfunction before or after liver transplantation remains a complicated, multifaceted, and critical issue that adversely affects a host of outcomes, which range from increased costs of care to inferior grafts and decreased patient survival. The

Early serum tacrolimus levels predict long-term chronic kidney disease after liver transplantation

“…However, different studies have shown that the MELD-score predicted neither the development of advanced CKD nor mortality more than one year after LT, 5,12,33,37 which is in agreement with our findings since, even in the univariate analysis, this variable was not associated with CKD stage or mortality, two years post-LT.…”

MELD Era Increases the Number of Combined Liver and Kidney Transplantations

“…In addition, there is an increased morbidity associated with renal insufficiency, so it would not be surprising if lower survival rates were observed in patients who underwent CLKT. In fact, if the transplanted kidney works, this can minimize these problems and can be better for the patient than undergoing dialysis after transplantation [2,8,10].…”

“…Indication to combined procedure is straightforward in patients under dialyses. Conversely, in those patients with potentially reversible kidney failure can be difficult to predict whether the native kidney will recovery sufficiently after LT alone [2,4,7,11]. In our institute, we consider more than 8 weeks of dialysis given at least 2 times per week to indicate the CLKT procedure.…”

“…In advanced stages of disease, transplantation is the only effective intervention strategy to increase survival [1,2].…”

Liver Transplantation: An Appraisal of the Present Situation

“…Table 1 lists the most important side effects of the immunosuppressants which are currently available. End-stage renal failure requiring kidney transplantation occurs 10 years after LT (as well as after heart transplantation) in up to 20% of patients, which is, at least in part, caused by the nephrotoxicity of calcineurin inhibitors [18]. In some patients, withdrawal of these drugs and replacement by derivatives of mycophenolic acid or by mTOR inhibitors may be successful.…”