title: Transplantation: impact of pretransplant renal insufficiency.
abstract: Pre-liver transplant renal dysfunction is associated with decreased survival following transplantation and is also a prognostic indicator of posttransplant chronic kidney disease. Selection of patients for combined liver/kidney transplantation versus orthotopic liver transplantation alone (OLTa) is often difficult given the lack of a reliable method to predict which patients will have ongoing severe renal dysfunction in the absence of concomitant kidney transplantation. We hypothesized that most patients with pretransplant renal dysfunction (serum creatinine > or = 1.5 mg/dL for at least 2 weeks prior to and at time of transplant) will not experience a rapid decline in estimated glomerular filtration rates (eGF) post-OLTa to the point of necessitating consideration for kidney transplantation, even in the setting of calcineurin inhibitor-based immunosuppression. We performed a single-center retrospective study of 60 OLTa patients with pretransplant renal dysfunction transplanted between 2000 and 2005. Kaplan-Meier analysis was performed of the time interval to develop eGFR < 20 mL/minute post-OLTa. At OLTa, the mean patient age was 59 years, and median serum creatinine was 1.8 mg/dL; 42% patients were hepatitis C-positive, 32% were diabetic, 38% had kidney dysfunction > 12 weeks, and 5% were receiving hemodialysis. After 36 months median follow-up post-OLTa, only 8 patients (13%) with significant renal dysfunction pre-OLTa achieved eGFR < 20 mL/minute. Patients with pretransplant kidney dysfunction > 12 weeks were at increased risk for eGFR < 20 mL/minute (hazard ratio = 5.3, P = 0.04), a risk that escalated after adjustment for age and serum creatinine at transplant (hazard ratio = 8.9, P = 0.01). Significant predictors of eGFR < 20 mL/minute post-OLTa in this patient cohort were the presence of diabetes and the serum creatinine level at transplant. In conclusion, few patients with preexisting renal dysfunction, especially if <12 weeks duration, experience a significant drop in eGFR post-OLTa.
authors.affiliation: Division of Hepatology, University of Pennsylvania Health System, Philadelphia, PA 19010, USA.
authors.forename: Ranjeeta
authors.initials: R
authors.lastname: Bahirwani
authors.forename: Mical S
authors.initials: MS
authors.lastname: Campbell
authors.forename: Tim
authors.initials: T
authors.lastname: Siropaides
authors.forename: James
authors.initials: J
authors.lastname: Markmann
authors.forename: Kim
authors.initials: K
authors.lastname: Olthoff
authors.forename: Abraham
authors.initials: A
authors.lastname: Shaked
authors.forename: Roy D
authors.initials: RD
authors.lastname: Bloom
authors.forename: K Rajender
authors.initials: KR
authors.lastname: Reddy
mesh_terms: D000368:Aged; D003404:Creatinine / Q000097:blood; D048909:Diabetes Complications / Q000601:surgery; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate; D006801:Humans; D007676:Kidney Failure, Chronic / Q000097:blood / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy; D016030:Kidney Transplantation; D008107:Liver Diseases / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D016016:Proportional Hazards Models; D020127:Recovery of Function; D006435:Renal Dialysis; D051437:Renal Insufficiency / Q000150:complications* / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D003404:Creatinine