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Renal dysfunction and orthotopic liver transplantation: management strategies and indications for combined liver and kidney transplantation

Purpose of reviewTransplant clinicians must deal with renal dysfunction in patients waiting for liver transplant and in the patient after transplant. The purpose of this review is to examine new advances in the treatment of renal dysfunction before transplant, the indications and outcomes for combined liver kidney transplant, and recent advances in treating the renal dysfunction that occurs after liver transplant as a consequence of treatment with immunosuppressive drugs. Recent findingsNew strategies for the treatment of renal dysfunction including hepatorenal syndrome that occurs before liver transplant have been described. These include albumin, terlipressin, transjugular intrahepatic portosystemic shunts, and albumin dialysis. Results of combined liver kidney transplant have been reviewed using the UNOS database and confirm that the procedure is viable but limited by decreased patient survival compared with patients receiving kidney transplant alone. It has also been confirmed that there is less renal rejection in the combined transplants. Finally, strategies using calcineurin minimization, mycophenolate mofetil, and sirolimus have addressed the growing problem with long-term nephrotoxicity secondary to calcineurin inhibitors. It has been recognized that as many as 12% of long-term liver transplant survivors develop end-stage renal disease. SummaryRenal dysfunction is a growing problem in patients awaiting liver transplant. New strategies have been developed to deal with this problem. Combined liver/kidney transplant is a viable option for the patient with combined end-organ damage. There is growing concern over the long-term consequence of chronic calcineurin inhibitor therapy for chronic kidney disease and end-stage renal disease. Multiple new strategies to deal with this have been proposed. They have had variable success, and further research is needed.