Pre‐liver transplant renal dysfunction and association with post‐transplant end‐stage renal disease: A single‐center examination of updated UNOS recommendations

Abstract

Simultaneous liver‐kidney allocation protocols allocate dual organs based on a sustained eGFR of 30 mL/min or less. A 2017‐UNOS update includes CKD3 as dual organ candidates but only when the listing eGFR is <30 mL/min while recommending a "safety net" for prioritized kidney listing post‐LT. We retrospectively reviewed adult LTs examine whether the UNOS proposal captured the LT population at highest risk for developing post‐LT ESRD. Among 290 LT recipients, 67 had pre‐LT CKD3, 141 had AKI, of whom 47 required dialysis (<4 weeks). During follow‐up, 25 (8.62%) developed ESRD, while 70 (24.1%) died. In adjusted Cox models, CKD3 had an independent association with post‐LT ESRD (adjusted HR 4.8; P = 0.001), independent of AKI. Interestingly, CKD3 with listing GFR >30 mL/min was still significantly associated with post‐LT ESRD. AKI was associated with reduced post‐LT survival (adjusted HR 1.9; P = 0.02), albeit only in the first‐year post‐LT. Severe AKI‐D was associated with post‐LT ESRD and mortality. The safety net would have captured only 60% of all post‐LT ESRD cases in our cohort. Pre‐LT CKD3 was associated with increased risk of post‐LT ESRD above the recommended cutoff for listing GFR. These findings, if generalizable in larger cohorts have important implications for dual organ allocation.

Hepatorenal syndrome: pathophysiology, diagnosis, and management

“…147 Despite best efforts, almost 10% of patients with either AKI or CKD who receive a liver alone may have persistent or progressive renal failure after transplant. 148 Patients with ATN are at particularly increased risk of chronic kidney disease (stage 4 or 5) posttransplant, and the lack of ideal biomarkers often results in misdiagnosis. 149 This has led to a consensus "safety net" for prioritization of liver recipients on the kidney waiting list if they are registered within a year after their liver transplant.…”

A Systematic Review of the Literature on Chronic Kidney Disease Following Liver Transplantation

“…All studies except Yoon et al and Chauhan et al assessed treatment regimens that included tacrolimus ( Table 3 ). Patients in the study by Yoon et al generally received CNI-based regimens, while treatment regimens were not reported by Chauhan et al [ 20 , 21 ].…”

“…Where mean patient age was reported, this was between 48.5 and 61.5 years across studies and study arms. When information was available, ≥78.1% of patients were White; the exception was Chauhan et al, in which 36.3–43.3% of patients across study arms were White [ 20 ]. The primary diseases at baseline varied between studies and study arms ( Table 4 ), but included alcoholism or ethanol abuse (23.1–71.4% across 3 studies [ 23 , 24 , 29 ]) hepatitis C virus infection (0–41.8% in 11 studies [ 7 , 19 , 20 , 22 – 26 , 28 – 30 ]), and hepatocellular carcinoma (2.3–63.6% in 10 studies [ 7 , 19 – 22 , 24 , 27 – 30 ]).…”

A meta‐analysis on the prevalence of chronic kidney disease in liver transplant candidates and its associated risk factors and outcomes

“…The population samples consisted of liver transplant recipients identified by the respective institutions. They originated from nine different countries with five from USA [5,14,18,34,35] three from Japan Chronic kidney disease in liver transplant candidates [2,9,36] one from Korea [37], one from Taiwan [6], one from Germany [17], one from Brazil [38], one from Turkey [39], one from Italy [40], and one from Switzerland [13]. Mean age of CKD patients ranged from 46.8 years to 58.7 years, while mean age of non-CKD patients ranged from 46.3 years to 56.3 years.…”

“…Advancements in the field of liver transplantation (LT) have yielded drastic improvements in short-term graft and patient survival outcomes [1,2]. However, the development of chronic kidney disease (CKD) before liver transplant persists as a complicated, multifaceted issue leading to a multitude of adverse outcomes including inferior graft survival, increased infection, increased health care cost, and longer duration of stay [3][4][5][6][7]. Patients with pre-LT CKD suffer increased intraoperative blood loss and haemostatic abnormalities, bearing a 15% increased risk of post-operative mortality [8,9].…”