Post–Liver Transplant Acute Kidney Injury

Abstract

Acute kidney injury (AKI) is a common condition following liver transplantation (LT). It negatively impacts patient outcomes by increasingthe chances of developing chronic kidney disease and reducing graft and patient survival rates. Multiple definitions of AKI have been proposed and used throughout the years, with the International Club of Ascites definition being the most widely now used for patients with cirrhosis. Multiple factors are associated with the development of post-LT AKI and can be categorized into pre-LT comorbidities, donor and recipient characteristics, operative factors, and post-LT factors. Many of these factors can be optimized in an attempt to minimize the risk of AKI occurring and to improve renal function if AKI is already present. A special consideration during the post-LT phase is needed for immunosuppression as certain immunosuppressive medications can be nephrotoxic. The calcineurin inhibitor tacrolimus (TAC) is the mainstay of immunosuppression but can result in AKI. Several strategies including use of the monoclonoal antibody basilixamab to allow for delayed initiation of tacrolimus therapy and minimization through combination and minimization or elimination of TAC through combination with mycophenolate mofetil or mammalian target of rapamycin inhibitors have been implemented to reverse and avoid AKI in the post-LT setting. Renal replacement therapy may ultimately be required to support patients until recovery of AKI after LT. Overall, by improving renal function in post-LT patients with AKI, outcomes can be improved.

Association between gut colonization of vancomycin‐resistant enterococci and liver transplant outcomes

“…9 These patterns of microbiota disruption characterized by dominance of a single taxa and loss of diversity were significant predictors of mortality in allogeneic hematopoietic-cell transplantation. 26 Furthermore, gut dysbiosis may 29 In our cohort, VRE colonization was associated with higher pretransplant levels of creatinine (and MELD scores) that may explain in part the higher risk of AKI posttransplant. VRE colonization-associated dysbiosis may also contribute to the increased risk of AKI.…”

Are short‐term complications associated with poor allograft and patient survival after liver transplantation? A systematic review of the literature and expert panel recommendations

“…For example, Dong and colleagues identified several preoperative risk factors for developing AKI after LT, including high BMI, preexisting hypertension, type 2 diabetes, reduced donor liver quality, and hepatorenal syndrome. 55 Preoperative risk factors for developing EAD 27,47 and biliary complications 32,56,57 after LT have also been identified in the literature. Transplant centers should consider monitoring patients with these comorbidities closely and apply appropriate interventions to prevent the AKI, biliary complications, and EAD from occurring whenever possible.…”

“…58 Poor donor allograft quality and interoperative factors may also increase a recipient's chances of developing AKI. 55 Calcineurin inhibitors (CNIs) used for immunosuppression after transplant are known to be nephrotoxic, and they may contribute to AKI after LT. Immunosuppression protocols that delay the use of CNIs have been shown to protect kidney function. 51 However, a recent twocenter study by Ciria and colleagues suggested that lower-dose use of the CNI tacrolimus had no affect the development of AKI and may not significantly impact post-LT renal function in patients with normal preoperative renal function.…”

“…or more of post-LT patients. 55 Although the exact mechanisms behind the association are not fully known in all cases, patients who need LT often have impaired kidney function post-transplant. Some patients have reduced kidney function before LT; these patients do much worse after LT and are more likely to require RRT.…”

Highly pathogenic coronaviruses and the kidney

“…Tacrolimus is metabolized by the cytochrome P450 3A4 enzyme system, and many drugs can induce or inhibit this enzyme, affecting its levels. It can cause serious side effects such as AKI and is a hazard that deserves our attention, although there hasn't been much research [92] . Interestingly, some glucocorticoid drugs may cause kidney damage in the anti-inflammatory treatment of COVID-19 and in the rescue of critically ill patients [93] , [94] .…”