Native kidney function following liver transplantation using calcineurin inhibitors: single-center analysis with 20 years of follow-up

Abstract

Introduction: The incidence of chronic kidney disease (CKD) in liver transplant recipients has been estimated to be from 18% to 28% at 10 yr after transplantation. As outcomes from liver transplantation continue to improve, long-term native kidney function in these recipients becomes more critical to patient survival.

Methods: We analyzed 1151 adult, deceased-donor, single-organ primary liver transplantations performed at our center between 7/17/84 and 12/31/07. Analysis of renal function was performed on 972 patients with liver allograft survival >1 yr.

Results: Kaplan-Meier analysis revealed that 3%, 7%, and 18% of liver transplant recipients with allograft survival >1 yr developed end-stage renal disease (ESRD) at five, 10, and 20 yr, respectively. Significant independent risk factors for ESRD included dialysis during the transplant hospitalization, the stage of CKD at one yr, hypercholesterolemia, non-Caucasian race, and hepatitis C as the primary indication for liver transplantation. The initial immunosuppression of essentially all recipients was a calcineurin inhibitor-based regimen.

Conclusion: Close, long-term follow-up of liver transplant recipients permits optimal management of liver allograft and native renal function and can lead to excellent long-term outcomes despite a calcineurin inhibitor-based immunosuppressive regimen.

Figure 1

Development of ESRD. ESRD, defined as either renal transplantation or dialysis-dependence, is not uncommon following liver transplantation. The incidence of ESRD was 3%, 7%, and 16% at 5, 10, and 15 years post-transplant, respectively. The number of patients at risk is depicted beneath the time points.

Figure 2

The estimated GFR decreases over time. The GFR of the overall cohort was 57 ml/min/1.73 m², 54 ml/min/1.73 m², 49 ml/min/1.73 m², and 43 ml/min/1.73 m² at 1, 5, 10, and 15 years, respectively. The effect is more pronounced in patients undergoing liver transplantation in the earlier period of the study (prior to the year 2000).

Figure 3

Progression of CKD stage between time of transplant and one year. Stage progression of CKD occurs in the majority of patients during the first year following liver transplantation. At the time of transplant, the majority of patients are evenly distributed between CKD Stage 1, 2, and 3. However, by one year, there is a preponderance of patients with Stage 2 and 3 CKD.

Figure 4

Stage of CKD at one year, and the risk of the subsequent development of ESRD. The stage of CKD at one year was a significant risk factor for ESRD. Although no patients with Stage 1 CKD developed ESRD, Kaplan-Meier estimates indicate that nearly 20 percent of patients with Stage 4 CKD will develop ESRD by fifteen years post-transplant.