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Acute Kidney Injury After Liver Transplantation

Durand, François, MD1; Francoz, Claire, MD1; Asrani, Sumeet K., MD2; Khemichian, Saro, MD3; Pham, Thomas A., MD4; Sung, Randall S., MD5; Genyk, Yuri S., MD4; Nadim, Mitra K., MD6

doi: 10.1097/TP.0000000000002305

Since the implementation of the Model of End-stage Liver Disease score-based allocation system, the number of transplant candidates with impaired renal function has increased. The aims of this review are to present new insights in the definitions and predisposing factors that result in acute kidney injury (AKI), and to propose guidelines for the prevention and treatment of postliver transplantation (LT) AKI. This review is based on both systematic review of relevant literature and expert opinion. Pretransplant AKI is associated with posttransplant morbidity, including prolonged post-LT AKI which then predisposes to posttransplant chronic kidney disease. Prevention of posttransplant AKI is essential in the improvement of long-term outcomes. Accurate assessment of baseline kidney function at evaluation is necessary, taking into account that serum creatinine overestimates glomerular filtration rate. New diagnostic criteria for AKI have been integrated with traditional approaches in patients with cirrhosis to potentially identify AKI earlier and improve outcomes. Delayed introduction or complete elimination of calcineurin inhibitors during the first weeks post-LT in patients with early posttransplant AKI may improve glomerular filtration rate in high risk patients but with higher rates of rejection and more adverse events. Biomarkers may in the future provide diagnostic information such as etiology of AKI, and prognostic information on renal recovery post-LT, and potentially impact the decision for simultaneous liver-kidney transplantation. Overall, more attention should be paid to pretransplant and early posttransplant AKI to reduce the burden of late chronic kidney disease.

The authors provide a comprehensive review of the current understanding of acute kidney injury in liver transplant patients. Guidelines for prevention and treatment of acute kidney injury are provided based on a systematic literature review and expert opinion.

1 Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, France, University Paris Diderot, Paris, France.

2 Division of Hepatology, Baylor University Medical Center, Dallas, TX.

3 Division of Gastrointestinal and Liver Disease, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA.

4 Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.

5 Section of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, MI.

6 Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA.

Received 11 January 2018. Revision received 26 April 2018.

Accepted 15 May 2018.

The authors declare no funding or conflicts of interest.

All authors participated in writing of the article.

Correspondence: Mitra K. Nadim, MD, Division of Nephrology and Hypertension, Department of Medicine, University of Southern California 1520 San Pablo St., Suite 4300 Los Angeles, CA 90033. (

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