Rethinking chronic kidney disease risk after liver transplantation

In this editorial, we comment on the article by Muñoz-Serrano et al published in the World Journal of Transplantation. Chronic kidney disease (CKD) is one of the most frequent and severe complications after liver transplantation (LT), threatening long-term survival beyond graft-related issues. Its pathogenesis is multifactorial, combining calcineurin inhibitor (CNI) nephrotoxicity with pre- and perioperative renal insults and metabolic comorbidities. We reviewed recent evidence from clinical trials, meta-analyses, and practice guidelines evaluating risk factors and management of CKD after LT, with a focus on immunosuppression strategies, perioperative care, and prognostic determinants. CKD develops in approximately 30% of LT recipients at 1 year and exceeds 40% at 5 years, with stage G3 predominating. Key predictors of post-LT CKD include high pre-LT creatinine [odds ratio (OR) = 7.74], early post-LT acute kidney injury (OR = 2.72), hypertension (OR = 4.833), and metabolic dysfunction-associated steatotic liver disease, including non-alcoholic steatohepatitis, as the underlying etiology. Tacrolimus remains superior to cyclosporine in overall survival and hypertension control, though hypomagnesemia and diabetogenicity are clinically relevant toxicities. CNI minimization - through basiliximab induction, low-dose tacrolimus with mycophenolate, or everolimus conversion - improves renal outcomes without compromising graft survival, despite trade-offs such as mild acute rejection or higher malignancy rates. CKD at 1 year confers a 4.48-fold increase in mortality risk, underscoring the prognostic weight of renal preservation. Renal protection after LT requires systematic preoperative risk stratification, perioperative CNI minimization, individualized immunosuppression, and aggressive metabolic management. Future integration of non-invasive biomarkers, including kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin, together with standardized simultaneous liver-kidney transplantation criteria, may further refine patient-tailored nephroprotection strategies. Muñoz-Serrano et al retrospectively analyzed 594 liver transplant recipients over three decades to identify risk factors for CKD at one year post-transplant. The authors identified older age, female sex, pre-transplant renal dysfunction, and treatment with cyclosporine A as independent risk factors.