Renal Outcomes of Liver Transplant Recipients Who Had Pretransplant Kidney Biopsy

Wadei, Hani M.; Heckman, Michael G.; Rawal, Bhupendra; Taner, C. Burcin; Martin, L.; Cortese, Cherise; Rosser, Barry G.; Gonwa, Thomas A.; Keaveny, Andrew P.

doi:10.1097/tp.0000000000000215

Cited by 24 publications

(18 citation statements)

References 21 publications

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“…The imprecision of creatinine‐based estimates of GFR in the setting of decompensated liver disease, although well‐known, is also difficult to accurately account for in clinical practice, making pre‐LT estimates of renal dysfunction less reliable . While biopsy criteria have been suggested to quantify irreversible damage objectively, the performance of renal biopsies is infrequent in clinical practice, limited by end‐stage liver disease coagulopathy, and was associated with ~10% incidence of renal arterial embolization in a series from a tertiary referral center . Hence, the critical level of pre‐LT renal dysfunction (ie, CKD3 and listing eGFR) that best captures the presence of irreversible renal damage, that would then accurately reflect the post‐LT risk of ESRD and mortality has been a source of debate.…”

Section: Discussionmentioning

confidence: 99%

“…12 While biopsy criteria have been suggested to quantify irreversible damage objectively, the performance of renal biopsies is infrequent in clinical practice, limited by end-stage liver disease coagulopathy, and was associated with ~10% incidence of renal arterial embolization in a series from a tertiary referral center. 13 Hence, the critical level of pre-LT renal dysfunction (ie, CKD3…”

Section: Discussionmentioning

confidence: 99%

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

Chauhan

Azzi

Faddoul

et al. 2018

Clinical Transplantation

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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

Chauhan

Azzi

Faddoul

et al. 2018

Clinical Transplantation

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“…In addition, post-LT factors such as calcineurin inhibitor (CNI) use have been linked to post-LT renal dysfunction (1). Our group previously demonstrated that peri-LT events including infections and need for surgical reexploration are associated with post-LT renal dysfunction, even in patients who had normal histology on pre-LT renal biopsy (7).…”

Section: Introductionmentioning

confidence: 99%

Early Allograft Dysfunction After Liver Transplantation Is Associated With Short- and Long-Term Kidney Function Impairment

Wadei

Lee

Croome

et al. 2016

American Journal of Transplantation

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Early allograft dysfunction (EAD) after liver transplantation (LT) is related to ischemia-reperfusion injury and may lead to a systemic inflammatory response and extrahepatic organ dysfunction. We evaluated the effect of EAD on new-onset acute kidney injury (AKI) requiring renal replacement therapy within the first month and end-stage renal disease (ESRD) within the first year post-LT in 1325 primary LT recipients. EAD developed in 358 (27%) of recipients. Seventy-one (5.6%) recipients developed AKI and 38 (2.9%) developed ESRD. Compared with those without EAD, recipients with EAD had a higher risk of AKI and ESRD (4% vs. 9% and 2% vs. 6%, respectively, p < 0.001 for both). Multivariate logistic regression analysis showed an independent relationship between EAD and AKI as well as ESRD (odds ratio 3.5, 95% confidence interval 1.9-6.4, and odds ratio 3.1, 95% confidence interval 11.9-91.2, respectively). Patients who experienced both EAD and AKI had inferior 1-, 3-, 5-, and 10-year patient and graft survival compared with those with either EAD or AKI alone, while those who had neither AKI nor EAD had the best outcomes (p < 0.001). Post-LT EAD is a risk factor for both AKI and ESRD and should be considered a target for future intervention to reduce post-LT short-and long-term renal dysfunction.

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“…The biopsy procedure has been described previously . Briefly, the international normalized ratio (INR) and platelet count were measured prior to the biopsy, and fresh frozen plasma (FFP) and/or single‐donor platelets were transfused if the INR was >1.5 or if the platelet count was <50,000/mL.…”

Section: Methodsmentioning

confidence: 99%

“…The biopsy procedure has been described previously. (9,12) Briefly, the international normalized ratio (INR) and platelet count were measured prior to the biopsy, and fresh frozen plasma (FFP) and/or singledonor platelets were transfused if the INR was >1.5 or if the platelet count was <50,000/mL. After FFP and/or platelet transfusion(s), a repeat INR and/or platelet count was obtained, and further transfusion(s) were provided as necessary to achieve an INR ≤1.5 and a platelet count >50,000/mL.…”

Section: Renal Biopsy Proceduresmentioning

confidence: 99%

Arterial Blood Pressure at Liver Transplant Evaluation Predicts Renal Histology in Candidates With Renal Dysfunction

Wadei¹,

Abader²,

Alsaad³

et al. 2019

Liver Transpl

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Renal dysfunction is common in liver transplantation (LT) candidates, but differentiating between reversible and irreversible renal injury can be difficult. Kidney biopsy might be helpful in differentiating reversible from irreversible renal injury, but it is associated with significant complications. We aimed to identify pre‐LT predictors of potentially reversible renal injury using histological information obtained on pre‐LT renal biopsy. Data on 128 LT candidates who underwent pre‐LT kidney biopsy were retrospectively collected and correlated with renal histological findings. Indications for kidney biopsy were iothalamate glomerular filtration rate (iGFR) ≤40 mL/minute, proteinuria >500 mg/day, and/or hematuria. According to the biopsy diagnosis, patients were grouped into the following categories: normal (n = 13); acute tubular necrosis (ATN; n = 25); membranoproliferative glomerulonephritis (n = 19); minimal histological changes (n = 24); and advanced interstitial fibrosis (IF) and glomerulosclerosis (GS) (n = 47). Compared with patients having advanced IF/GS, patients with normal biopsies and those with ATN had lower systolic blood pressure (SBP) and diastolic blood pressure (DBP) and higher international normalized ratio and total bilirubin levels (<0.05 for all). Both SBP and DBP directly correlated with the degree of IF and GS (R = 0.3, P ≤ 0.02 for all). SBP ≤90 mm Hg was 100% sensitive and 98% specific in correlating with normal biopsies or ATN, whereas SBP ≥140 mm Hg was 22% sensitive and 90% specific in correlating with advanced IF/GS. Model for End‐Stage Liver Disease score, serum creatinine, iGFR, urinary sodium excretion, and renal size did not correlate with biopsy diagnosis or degree of IF or GS. In conclusion, SBP at the time of LT evaluation correlates with renal histology, and it should be included along with other clinical and laboratory markers in the decision‐making process to list patients with renal dysfunction for LT alone versus simultaneous liver‐kidney transplantation.

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Renal Outcomes of Liver Transplant Recipients Who Had Pretransplant Kidney Biopsy

Abstract: The most LT recipients with minimal chronic changes on pre-LT kidney biopsy recovered kidney function within 1 month from LT. A small but significant percentage met criteria for kidney transplantation at 1 year because of the development of unforeseen post-LT complications.

Cited by 24 publications

References 21 publications

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

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

Early Allograft Dysfunction After Liver Transplantation Is Associated With Short- and Long-Term Kidney Function Impairment

Arterial Blood Pressure at Liver Transplant Evaluation Predicts Renal Histology in Candidates With Renal Dysfunction

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