Incidence and Outcome of Renal Failure in Liver Transplantation

With improvements of surgical techniques and peri-operative care, survival of liver transplant patients has continuously improved over the last decades. Unfortunately, this trend is accompanied by a growing incidence of chronic renal failure. Also, due to the introduction of the MELD system, a large proportion of patients present with some degree of renal dysfunction prior to transplantation, which increases the risk of acute renal failure postoperatively. Depending on the criteria applied, reported incidences for acute and chronic renal failure in liver transplant recipients vary between 4% and 95%. Whereas acute renal failure most often is a reversible state that can be controlled, early detection and prevention of chronic renal failure remains a difficult task. Since currently used clinical markers to monitor nephrotoxicity, like serum creatinine, can not successfully discriminate patients at risk, the focus should shift to new diagnostic tools which could identify at-risk patients earlier and allow for kidney rescue therapies to commence before structural damage occurs. The new strategies could facilitate an individualization of immunosuppressive therapy. A review of current literature shows that calcineurin inhibitor toxicity represents the most significant factor for the development of acute and chronic renal dysfunction beside factors like preexisting renal dysfunction or hepatorenal syndrome, liver allograft dysfunction, diabetes or hepatitis C that have been reported to be associated with the incidence of renal failure following transplantation. Despite their shortcomings, calcineurin inhibitors (CNI’s) remain the best alternative for preventing allograft rejection. No alternative drugs seem either potent or safe enough to entirely replace CNI’s. Thus, active strategies should concentrate on optimizing CNI treatment protocols with early detection markers for toxicity, paired with the conversion to alternative drugs such as MMF and sirolimus.