[Renal failure following liver transplantation]

Area of Science:

• Nephrology
• Hepatology
• Transplantation Medicine

Context:

• Liver transplantation (LT) recipients face a high cumulative incidence of chronic kidney disease (CKD), with rates exceeding 50% by 5 years post-transplant.
• Pre-end-stage renal failure also affects a significant proportion, reaching 10-20% at 5 and 10 years.
• Several pre-transplant and post-operative factors are independently associated with the development of kidney failure.

Purpose:

• To summarize the incidence, risk factors, and causes of chronic kidney disease (CKD) following liver transplantation (LT).
• To discuss the role of calcineurin inhibitors and other contributing factors in post-LT kidney failure.
• To highlight the need for early intervention and alternative immunosuppressive strategies to prevent nephrotoxicity.

Summary:

• The incidence of CKD post-LT is substantial (40-50% at 1 year, >50% at 5 years).
• Risk factors include age, male sex, non-Asian ethnicity, low pre-transplant GFR, pre-existing diabetes, HCV carriage, and post-operative acute kidney injury.
• Calcineurin inhibitors (cyclosporine, tacrolimus), diabetes, and nephroangiosclerosis are major contributors to kidney damage, which is often irreversible.

Impact:

• Early detection and intervention are crucial for managing kidney function post-LT.
• Reducing calcineurin inhibitor dosage, rather than just blood concentration, is key to improving renal function.
• Non-nephrotoxic immunosuppressants (e.g., mycophenolate mofetil, mTOR inhibitors) and managing comorbidities like hypertension and diabetes can aid in nephroprotection.