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. 2014 Aug;61(2):286-92.
doi: 10.1016/j.jhep.2014.03.034. Epub 2014 Apr 5.

Chronic kidney disease and associated mortality after liver transplantation--a time-dependent analysis using measured glomerular filtration rate

Alina M Allen  1 , W Ray Kim  2 , Terry M Therneau  3 , Joseph J Larson  3 , Julie K Heimbach  4 , Andrew D Rule  5
Affiliations

Chronic kidney disease and associated mortality after liver transplantation--a time-dependent analysis using measured glomerular filtration rate

Alina M Allen et al. J Hepatol. 2014 Aug.

Abstract

Background & aims: The accuracy of creatinine-based estimated GFR (eGFR) in assessing the prevalence of chronic kidney disease (CKD) and associated mortality after liver transplantation (LTx) is unknown. Using measured GFR (mGFR) by iothalamate clearance, we determined the prevalence of the entire spectrum of renal dysfunction and the impact of CKD on mortality after LTx.

Methods: A database that prospectively tracks all LTx recipients at this academic transplant program from 1985 to 2012 was queried to identify all adult primary LTx recipients. Our post-LTx protocol incorporates GFR measurement by iothalamate clearance at regular intervals. A multistate model was used to assess the prevalence of CKD, kidney transplant, and death after LTx. Time-dependent Cox regression analysis was performed to evaluate the impact of mGFR and eGFR changes on survival.

Results: A total of 1211 transplant recipients were included. At the time of LTx, the median age was 54 years, 60% were male and 86% were Caucasian. At 25 years after LTx, 54% of patients died, 9% underwent kidney transplantation, whereas 7%, 21%, and 18% had mGFR >60, 59-30, and <30 ml/min/1.73 m(2) respectively. The risk of death increased when mGFR decreased below 30 ml/min/1.73 m(2): HR = 2.67 (95% CI = 1.80-3.96) for GFR = 29-15 ml/min/1.73 m(2) and HR = 5.47 (95% CI = 3.10-9.65) for GFR <15 ml/min/1.73 m(2). Compared to mGFR, eGFR underestimated mortality risk in LTx recipients with an eGFR of 30-90 ml/min/1.73 m(2).

Conclusions: An overwhelming majority of LTx recipients develop CKD. The risk of death increases exponentially when GFR <30 ml/min/1.73 m(2). Creatinine-based eGFR underestimates the mortality risk in a large proportion of patients.

Keywords: Iothalamate clearance; Outcomes; Prevalence; Renal failure.

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Conflict of interest statement

Conflict of interest: The authors of this manuscript have no conflicts of interest to disclose as described by Journal of Hepatology.

Figures

Fig. 1
Fig. 1
Posttransplant renal function in patients who remain alive and without kidney transplant. (A) Estimated GFR by MDRD 4 (B) Measured GFR by iothalamate clearance.
Fig. 1
Fig. 1
Posttransplant renal function in patients who remain alive and without kidney transplant. (A) Estimated GFR by MDRD 4 (B) Measured GFR by iothalamate clearance.
Fig. 2
Fig. 2. Impact of measured GFR on mortality
The risk of death increases significantly when measured GFR decreased <30 ml/min/1.73m2. Dashed lines represent the 95% confidence interval.
Fig. 3
Fig. 3. Impact of estimated GFR on mortality
The risk of death increases exponentially when estimated GFR decreased below 30 ml/min/1.73m2. GFR>90 ml/min/1.73m2 is also associated with an increased risk of death. Dashed lines represent the 95% confidence interval.
Fig. 4
Fig. 4. Impact of serum creatinine on mortality
The risk of death is increased both at high and low creatinine levels. Dashed lines represent the 95% confidence interval.
See this image and copyright information in PMC

Comment in

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