Acute Kidney Injury After Liver Transplantation

  • Raymond M. Planinsic
  • Tetsuro Sakai
  • Ibtesam A. Hilmi


Acute kidney injury after liver transplantation is a frequent complication that is caused by a multitude of perioperative renal insults often in addition to pre-existing renal insufficiency. Its definition is problematic mostly because the basis of most definitions, serum creatinine is a poor and insensitive marker of renal injury. This chapter will review the epidemiology and common causes of acute kidney injury after liver transplantation.


The incidence of postoperative renal insufficiency and acute kidney injury (AKI) in patients undergoing liver transplantation ranges from 20% up to 90% [1] and more than 80% of these episodes occur within the first 2 postoperative days. Earlier studies found that mortality at 30 days was 50% in patients who developed AKI and 29% in non-AKI patients [2]. AKI necessitating renal replacement therapy has been associated with mortality rates from 55 to 90% [3]. More recent data confirmed that AKI is associated with increased...


Renal injury Chronic kidney disease Dialysis Renal replacement therapy Abdominal compartment syndrome Hemolytic uremic syndrome 


  1. 1.
    McCauley J, et al. Acute and chronic renal failure in liver transplantation. Nephron. 1990;55(2):121–8.CrossRefGoogle Scholar
  2. 2.
    Pascual E, et al. Incidence and risk factors of early acute renal failure in liver transplant patients. Transplant Proc. 1993;25(2):1827.Google Scholar
  3. 3.
    Ishitani M, et al. Outcome of patients requiring hemodialysis after liver transplantation. Transplant Proc. 1993;25(2):1762–3.PubMedGoogle Scholar
  4. 4.
    Hilmi IA, et al. Acute kidney injury following orthotopic liver transplantation: incidence, risk factors, and effects on patient and graft outcomes. Br J Anaesth. 2015;114(6):919–26. Scholar
  5. 5.
    Bellomo R, et al. Acute Dialysis Quality Initiative workgroup. Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004;8:R204–12.CrossRefGoogle Scholar
  6. 6.
    Mehta RL, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11(2):R31.CrossRefGoogle Scholar
  7. 7.
    Fraley DS, et al. Impact of acute renal failure on mortality in end-stage liver disease with or without transplant. Kidney Int. 1998;54:518–24.CrossRefGoogle Scholar
  8. 8.
    Wagener G, et al. Urinary neutrophil gelatinase-associated lipocalin as a marker of acute kidney injury after orthotopic liver transplantation. Nephrol Dial Transplant. 2011;26(5):1717–23.CrossRefGoogle Scholar
  9. 9.
    Niemann CU, et al. Acute kidney injury during liver transplantation as determined by neutrophil gelatinase-associated lipocalin. Liver Transpl. 2009;15(12):1852–60.CrossRefGoogle Scholar
  10. 10.
    Portal AJ, et al. Neutrophil gelatinase-associated lipocalin predicts acute kidney injury in patients undergoing liver transplantation. Liver Transpl. 2010;16(11):1257–66.CrossRefGoogle Scholar
  11. 11.
    Sirota J, et al. Urine IL-18, NGAL, IL-8 and serum IL-8 are biomarkers of acute kidney injury following liver transplantation. BMC Nephrol. 2013;14:17. Scholar
  12. 12.
    Esson ML, Schrier RW. Diagnosis and treatment of acute tubular necrosis. Ann Intern Med. 2002;137(9):744–52.CrossRefGoogle Scholar
  13. 13.
    Cotterell AH, et al. Calcineurin inhibitor-induced chronic nephrotoxicity in liver transplant patients is reversible using rapamycin as the primary immunosuppressive agent. Clin Transplant. 2002;16(Suppl 7):49–51.CrossRefGoogle Scholar
  14. 14.
    Gonwa TA, et al. Improved renal function in sirolimus-treated renal transplant patients after early cyclosporine elimination. Transplantation. 2002;74(11):1560–7.CrossRefGoogle Scholar
  15. 15.
    Benigni A, et al. Nature and mediators of renal lesions in kidney transplant patients given cyclosporine for more than one year. Kidney Int. 1999;55(2):674–85.CrossRefGoogle Scholar
  16. 16.
    Jurewicz WA, et al. Tracolimus versus cyclosporine immunosuppression: long-term outcome in renal transplantation. Nephrol Dial Transplant. 2003;18(Suppl 1):I7–11.CrossRefGoogle Scholar
  17. 17.
    Starzl TE, et al. Tolerogenic immunosuppression for organ transplantation. Lancet. 2003;361(9368):​1502–10.CrossRefGoogle Scholar
  18. 18.
    Cardarelli F, et al. The problem of late allograft loss in kidney transplantation. Minerva Urol Nefrol. 2003;55(1):1–11.PubMedGoogle Scholar
  19. 19.
    Ojo AO, et al. Chronic renal failure after transplantation of a nonrenal organ. N Engl J Med. 2003;349(10):931–40.CrossRefGoogle Scholar
  20. 20.
    Rerolle JP, et al. Tacrolimus-induced hemolytic uremic syndrome and end stage renal failure after liver transplantation. Clin Transpl. 2000;14(3):262–5.CrossRefGoogle Scholar
  21. 21.
    Evens AM, et al. TTP/HUS occurring in a simultaneous pancreas/kidney transplant recipient after clopidogrel treatment: evidence of a nonimmunological etiology. Transplantation. 2002;74(6):885–7.CrossRefGoogle Scholar
  22. 22.
    Yango A, et al. Successful treatment of tacrolimus-associated thrombotic microagiopathy with sirolimus conversion and plasma exchange. Clin Nephrol. 2002;58(1):77–8.CrossRefGoogle Scholar
  23. 23.
    Medina PJ, Sipols JM, George JN. Drug-associated thrombotic thrombocytopenia purpura-hemolytic uremic syndrome. Curr Opin Hematol. 2001;8(5):286–93.CrossRefGoogle Scholar
  24. 24.
    Holman MJ, et al. FK506 associated thrombotic thrombocytopenic purpura. Transplantation. 1993;55(1):205–6.CrossRefGoogle Scholar
  25. 25.
    Burch J, Moore F, Franciose R. The abdominal compartment syndrome. Surg Clin North Am. 1996;76:833–42.CrossRefGoogle Scholar
  26. 26.
    Malbrain M. Abdominal pressure in the critically ill patients. Intensive Care Med. 1999;25:1453–8.CrossRefGoogle Scholar
  27. 27.
    Cullen DJ, et al. Cardiovascular, pulmonary and renal effects of massively increased intra-abdominal pressure in critically ill patients. Crit Care Med. 1989;17:118–21.CrossRefGoogle Scholar
  28. 28.
    Biancofiore G, et al. Intra-abdominal pressure monitoring in liver transplant recipients: a prospective study. Intensive Care Med. 2003;29(1):30–6.CrossRefGoogle Scholar
  29. 29.
    Mogilner J, et al. Effect of elevated intra-abdominal pressure on portal vein and superior mesenteric artery blood flow in a rat. J Laparoendosc Adv Surg Tech A. 2009;19(Suppl 1):S59–62.CrossRefGoogle Scholar
  30. 30.
    Tsai JD, et al. Epstein-Barr virus-associated acute renal failure: diagnosis, treatment and follow-up. Pediatr Nephrol. 2003;18(7):667–74.PubMedGoogle Scholar
  31. 31.
    Collins MH, et al. Autopsy pathology of pediatric posttransplant lymphoproliferative disorder. Pediatrics. 2001;107(6):E89.CrossRefGoogle Scholar
  32. 32.
    Iwamoto S, et al. BK virus-associated fatal renal failure following late-onset hemorrhagic cystitis in an unrelated bone marrow transplant. Pediatr Hematol Oncol. 2002;19(4):255–61.CrossRefGoogle Scholar
  33. 33.
    Hirsch HH, et al. Prospective study of polyomavirus type BK replication and nephropathy in renal-transplant recipients. N Engl J Med. 2002;347(7):488–96.CrossRefGoogle Scholar
  34. 34.
    Elli A, et al. BK polyomavirus interstitial nephritis in a renal transplant patient with no previous acute rejection episodes. J Nephrol. 2002;15(3):313–6.PubMedGoogle Scholar
  35. 35.
    Hirsch HH, et al. Polyomavirus BK nephropathy: a (re-)emerging complication in renal transplantation. Am J Transplant. 2002;2(1):25–30.CrossRefGoogle Scholar
  36. 36.
    Marshall WF, et al. Survey of urine from transplant recipients for polyomavirus JC and BK using the polymerase chain reaction. Mol Cell Probes. 1991;5(2):125–8.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Raymond M. Planinsic
    • 1
  • Tetsuro Sakai
    • 1
  • Ibtesam A. Hilmi
    • 1
  1. 1.Department of AnesthesiologyUniversity of Pittsburgh Medical CenterPittsburghUSA

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