A s a result of the excellent long-term success of orthotopic liver transplantation (OLT), more recipients are eventually faced with the possibility of chronic renal failure (CRF) or end-stage renal disease (ESRD). At 13-year follow-up of 834 consecutive OLT recipients at a single transplant center, Gonwa et al. 1 found a 8.6% incidence of CRF and a 9.5% incidence of ESRD. As expected, patient survival was diminished in those that developed ESRD.
The pathogenesis of chronic renal insufficiency in OLT recipients is multifactorial. The most common contributor by far is calcineurin inhibitor nephrotoxicity. Gonwa et al. 1 have estimated that calcineurin inhibitor nephrotoxicity was responsible for 73.3% of the CRF in the 834 OLT recipients they studied. Progression of preexisting renal disease occurred in 11%, nonrecovery from hepatorenal syndrome in 6.7%, and de novo glomerular disease in 6.7%.
The progression of chronic renal insufficiency to ESRD after OLT is usually a late process. The incidence of ESRD is low during the 1st 5 years after transplantation, but then it increases steadily to reach an 18% incidence of severe renal insufficiency by posttransplantation year 13. 1 The serum creatinine during the 1st posttransplantation year correlates with the risk of progression to ESRD during long-term follow-up. In a multivariate analysis, Gonwa et al. 1 showed that increased serum creatinine measured over time was an independent predictor of increased risk. The odds ratio for development of CRF or ESRD was 1.59, 2.25, and 2.58 for each 1 mg/dL increase in serum creatinine at 4