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Long-term renal function in children after liver transplantation
Jesper M Kivelä1, Anne Räisänen-Sokolowski, Mikko P Pakarinen
1Department of Pediatric Nephrology and Transplantation, Hospital for Children and Adolescents, Helsinki University Central Hospital, Helsinki, Finland.
Insights
Long-term liver transplant recipients in children show declining kidney function, with a significant increase in chronic kidney disease stages over time. Cyclosporine A levels and proteinuria are key factors, highlighting the need for ongoing renal monitoring.
Area of Science:
- Pediatric Nephrology
- Transplantation Medicine
- Immunosuppression Management
Background:
- Reduced renal function is a significant long-term complication following pediatric liver transplantation (LT).
- Calcineurin inhibitor nephrotoxicity is a primary contributor to this post-transplant renal dysfunction.
- Long-term renal function surveillance is crucial for pediatric LT recipients.
Purpose of the Study:
- To evaluate long-term renal function in pediatric LT patients.
- To analyze the utility of various glomerular filtration rate (GFR) estimation methods in monitoring these patients.
- To identify factors influencing renal function decline after LT.
Main Methods:
- Inclusion of 57 pediatric patients undergoing LT.
- Serial measurement of GFR using 51-labeled chromium ethylenediaminetetraacetic acid clearance pre- and post-transplant.
- Correction of GFR with the modified Brochner-Mortensen equation and exclusion of outlier values.
- Analysis of GFR estimation methods (updated Schwartz, Schwartz 1987, Counahan-Barratt) against measured GFR.
Main Results:
- Mean GFR during follow-up was 76.0 mL/min/1.73 m2, with a significant decline observed between 5 and 7 years post-LT.
- The prevalence of stage 3 chronic kidney disease increased from 13% at 5 years to 33% at 15 years post-LT.
- Cyclosporine A trough levels and proteinuria were significant factors associated with renal function decline; GFR estimation methods showed varying degrees of overestimation compared to measured GFR.
Conclusions:
- Long-term renal function surveillance is essential for children following liver transplantation.
- While measured GFR is preferred, the updated Schwartz formula provides an acceptable estimation method for monitoring.
- Identifying and managing risk factors like immunosuppression and proteinuria is vital for preserving renal health post-LT.
Background:
Reduced renal function after liver transplantation (LT) is a long-term extrahepatic complication of major concern caused at least partly by calcineurin inhibitor nephrotoxicity. We report on long-term renal function after LT in children from a single center and analyze the usefulness of glomerular filtration rate (GFR) estimation methods in the follow-up of pediatric LT patients.
Methods:
Fifty-seven pediatric patients were included. GFRs were measured by 51-labeled chromium ethylenediaminetetraacetic acid clearance before LT, at discharge, 6, 12, 18, and 24 months after transplantation and annually thereafter and corrected with the modified Brochner-Mortensen equation. GFR values of cases with an ethylenediaminetetraacetic acid distribution volume less than 15% or more than 35% were excluded.
Results:
The mean GFR for overall follow-up was 76.0 mL/min/1.73 m2 (+/-22.2 mL/min/1.73 m2). The GFR declined significantly from 5 to 7 years (80.2 [+/-17.7] to 72.9 [+/-13.3] mL/min/1.73 m2, respectively; P<0.05). Thirteen percent, 21%, 31%, and 33% of patients had stage 3 chronic kidney disease at 5, 7, 10, and 15 years after LT, respectively. The cyclosporine A trough level was a significant time-dependent factor in the regression model, and after time was removed from the model, proteinuria was the most significant factor. GFR estimation methods overestimated measured GFR; 11% with updated Schwartz, 50% with Schwartz 1987, and 31% with Counahan-Barratt.
Conclusions:
This study underlines the importance of long-term renal function surveillance after LT performed on children. Although measuring GFR remains the preferred function surveillance method, the updated Schwartz formula is also acceptable.
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