The kidney in pediatric liver transplantation: An updated perspective

Abstract

CKD continues to detract from the success of improved survival in pediatric liver transplantation, and its presence is likely under recognized. Here we review the literature regarding the prevalence, etiology, and management of renal dysfunction in pediatric liver transplant recipients. Long-term studies suggest the prevalence of CKD to be 25-38% by 5-10 yr post-transplant. While important, sole use of serum creatinine overestimates renal function in this population. Screening for and treatment of persistent proteinuria and hypertension as well as minimization of nephrotoxic insults are the mainstays to delay or prevent CKD progression. Office-based blood pressure measures are less sensitive than ABPM, which is specifically recommended by the American Heart Association for its ability to diagnose masked hypertension in pediatric liver transplant recipients. Long-term risk of CKD is predominantly secondary to CNI toxicity. CNI minimization protocols have shown promise in slowing progression of CKD while maintaining graft function, but large-scale randomized control trials with long-term follow-up are needed.

Evaluation of renal functions in pediatric liver transplantation

“…Beyond the initial post‐transplant period, drug toxicity (calcineurin inhibitors) is an important contributor to the progression of CKD . We found that cyclosporine had a negative effect on GFR after LT, significant within the first six months and insignificant thereafter.…”

“…Pre‐existing renal disease, and peri‐ and post‐operative factors might predispose to the development of CKD in pediatric LT recipients . Metabolic disease, primary renal disease, hepatorenal syndrome, and drug toxicity are the pre‐operative risk factors for AKI development .…”

“…The incidence has been reported within a wide range due to both different definitions of AKI, and different methods for measuring or estimating GFR (1)(2)(3). AKI is an independent risk factor for increased morbidity and mortality in hospitalized patients including those who had LT (1,(4)(5)(6)(7)(8). Furthermore, emerging evidence suggests that episodes of AKI can lead to a progression toward CKD (7)(8)(9).…”

“…AKI is an independent risk factor for increased morbidity and mortality in hospitalized patients including those who had LT (1,(4)(5)(6)(7)(8). Furthermore, emerging evidence suggests that episodes of AKI can lead to a progression toward CKD (7)(8)(9). Perioperative period represents the time of greatest risk as hemodynamic instability, blood loss, and sepsis as well as direct toxic effects of medications might cause decreased renal perfusion (7).…”

Acute and chronic kidney disease after pediatric liver transplantation: An underestimated problem

“…Survival rates after pediatric LTx have been improved, but kidney disease impacts survival of children after transplantation. 96,97 In the early posttransplant period, acute renal damage is often described and, after some years from the transplant, a not negligible prevalence of CKD, between 25% and 38%, is reported. 3,15,98 One of the main determinant of this percentage is the presence of pre-transplant renal disease.…”