Key
Points 1. Pretransplant kidney function is an important predictor of posttransplant kidney function. 2. Chronic kidney disease is present in 20% of liver transplant recipients by 5 years. 3. Kidney function is impacted by pretransplant management of the consequences of the hepatorenal syndrome. 4. The use of calcineurin inhibitor (CNI) -based immunosuppression is an important factor in the development of chronic kidney disease, and the use of mycophenolic acid -or sirolimus-based immunosuppression with reduced-dose CNI may be of benefit. (Liver Transpl 2005;11:S47-S51.)
Factors Affecting Posttransplant Renal Function
Postoperative acute renal failure occurs in 17% to 95% of patients undergoing orthotopic liver transplantation (OLT). The difference in the incidence reported may be due in part to the wide disparity in the criteria used to define "acute renal failure." Nonetheless the commonly suggested etiologies of postoperative acute renal failure include acute tubular necrosis secondary to ischemic or toxic insult to the kidneys, preexisting hepatorenal syndrome (HRS), and drug-induced interstitial nephritis. [1][2][3] The former may include prolonged hypotension, sepsis or septic shock, sustained prerenal renal failure, and use of nephrotoxic drugs. Acute renal failure or declining renal function associated with the use of cyclosporine or tacrolimus in the posttransplantation period has been well described and is discussed in more detail below. Preoperative renal dysfunction, delayed liver graft function or primary graft nonfunction, and higher serum bilirubin level have also been variably shown to predispose OLT recipients to postoperative acute renal failure. [3][4][5] Chronic renal insufficiency, or chronic kidney disease, has been reported to occur in 4% to more than 80% of OLT recipients. 1,[6][7][8] The wide range in the incidence reported may be partly due to the difference in the criteria used to define chronic renal failure as well as the difference in the duration of follow-up. The commonly suggested causes or risk factors for the development of progressive chronic kidney disease or endstage renal disease (ESRD) in long-term survivors of OLT include calcineurin inhibitor nephrotoxicity, pre-OLT HRS, preexisting renal insufficiency, and diabetes mellitus. 3,5,7,8 Postoperative acute renal failure, dialysis requirement in the pretransplantation and/or posttransplantation period, hepatitis C infection, and age have also been variably shown to be associated with an increased risk for the development of chronic kidney disease. [8][9][10][11] In a study conducted by Fisher et al., severe chronic renal