Difficulties in diagnosing acute kidney injury post liver transplantation using serum creatinine based diagnostic criteria

Abstract

Renal function in patients with advanced cirrhosis is an important prognostic factor for survival both prior to and following liver transplantation. The importance of renal function is reflected by the introduction of the model for end stage liver disease (MELD) score, which includes serum creatinine. The MELD score has been shown to predict the short term risk of death for transplant wait listed patients and is currently used by many countries to allocate liver transplants on the basis of severity of underlying illness. Changes in serum creatinine are also used to stage acute kidney injury. However prior to liver transplantation the serum creatinine typically over estimates underlying renal function, particularly when a colorimetric Jaffe based assay is used, and paradoxically then under estimates renal function post liver transplantation, particularly when immunophyllins are started early as part of transplant immunosuppression. As acute kidney injury is defined by changes in serum creatinine, this potentially leads to over estimation of the incidence and severity of acute kidney injury in the immediate post-operative period. Key words: Serum creatinine; Acute kidney injury; Liver transplantationCore tip: Acute kidney injury is defined and severity graded based on changes in serum creatinine. Increasing concentrations of bilirubin interefere with laboratory determination of creatinine and reduce creatinine estimations. Post transplantation serum creatinine increases due to a combination of fall bilirubin and the loading doses of calcineurin inhibitor immunosupressants. This combination leads to an over estimation of the lesser grades of acute kidney injury post liver transplantation.Agarwal B, Davenport A. Difficulties in diagnosing acute kidney injury post liver transplantation using serum creatinine based diagnostic criteria. World J Hepatol 2014; 6(10): 696-703 Available from:

Acute kidney injury in acute-on-chronic liver failure: where does hepatorenal syndrome fit?

“…74 Although attempts to standardise measurements have been attempted, differences remain between assays and laboratories and these may contribute to differences in reporting AKI, and may lead to changes in clinical management. [82][83][84] Relying on measurement of serum creatinine as a surrogate for renal function although practical and universally available, most likely provides an under appreciation of renal dysfunction in patients with cirrhosis.…”

Perioperative acute kidney injury

“…All can affect sCr concentrations and under-or overestimate the incidence of AKI. 90 While some risk factors for liver transplantation-related AKI are similar to other high-risk surgeries, some risk factors are unique. 87 89 91 Accordingly, strategies to prevent liver transplantation-related AKI include the use of terlipressin 87 and avoiding or lowering the dose of tacrolimus after surgery.…”

Interlobar Artery Resistive Index predicts Acute-on-Chronic Liver Failure Syndrome in Cirrhotic Patients with Acute Decompensation

“…However, our study shows that the MELD score is marginally associated with ACLF development (not the MELD-Sodium) but was not sensitive enough to accurately predict ACLF development. This may be attributed to the fact that serum creatinine is one of the variables included in both scores; therefore, these scores also overestimate renal function [23,25,31]. Furthermore, according to the inclusion criteria used in this study, patients with elevated serum levels of creatinine or urea were excluded from this study.…”