Renal Function in Patients with Orthotopic Liver Transplantation

Abstract

Due to multiple reasons, acute renal failure (ARF) commonly develops in the early postoperative period of orthotopic liver transplantation (OLT) recipients. The records of OLT recipients between 1999 and 2004 were evaluated. Age, gender, primary disease, history of diabetes, immunosuppressive drugs, pre- and postoperative renal function tests, serum electrolytes, dialysis, liver functions tests, and renal function tests in follow-up period were noted. We followed 16 patients with OLT in our center. ARF developed in 8 patients. Dialysis was performed in only 2 patients, and other patients with ARF were managed with conservative measures. Hypertensive crisis and cerebrovascular stroke developed in 1 diabetic hypertensive patient.

Keywords:

• liver transplantation
• acute renal failure (ARF)

INTRODUCTION

Acute renal failure (ARF) and chronic renal failure has been reported in orthotopic liver transplantation (OLT) recipients. Major causes of ARF are ischemic acute tubular necrosis, calcineurin inhibitors, and sepsis. Mortality rates are much higher in uremic OLT recipients than patients with stable renal functions.[1] In this study, we assessed the renal functions of OLT recipients in our center.

PATIENTS AND METHOD

The records of OLT recipients between 1999 and 2004 were evaluated. Age, gender, primary disease, history of diabetes, immunosuppressive drugs, pre- and postoperative renal function tests, serum electrolytes, dialysis, liver functions tests, and renal function tests in follow-up period were noted. Hypertensive crisis and cerebrovascular stroke developed in one diabetic patient.

RESULTS

A total of 16 patients were assessed, and 13 of them were male. The median age was 44.5 (3.5 months–59 years). Underlying causes for liver transplantation were cirrhosis due to hepatitis B in 9 (56.5 %), alcoholic liver disease in 2 (12.5%), biliary athresis in 2 (12.5%), Wilson's cirrhosis in 2 (12.5%) and cryptogenic cirrhosis in 1 (6.5%). Two patients had diabetes mellitus, and 5 patients had a history of smoking. Ascites in 12 patients, history of hepatic coma in 5 patients, history of intestinal bleeding in 6 patients, usage of diuretics in 3 patients, and usage of beta-blocker in 4 patients were found. Fifteen patients had a history of hospitalization before operation. ARF developed in 8 patients, and 2 of 8 patients required dialysis. In the postoperative period, dopamine-furosemide was used in 10 patients. Among 16 patients, 5 patients died in the first 30 days and 1 patient died on the 120th day. Ten patients are in follow-up for 4 years. Patient's data are shown in Table 1. Renal and liver functions in follow-up period are shown in Table 2.

Table 1 Biochemical parameters and duration of disturbances of patients in postoperative period

Parameters	Postoperative levels	Duration of disturbances (day)	Parameters	Postoperative levels	Duration of disturbances (day)
Systolic BP (mmHg)	115.0 (28–165)		Albumin(g/dL)	2.7 (1–3.7)	25.0 (3–73)
Diastolic BP (mmHg)	65.0 (17–100)	6.0 (1–9)	AST(U/L)	1075.0 (74–7000)	30.0 (7–82)
Diuresis (mL/day)	700.0 (0–3310)	19.0 (4–34)	ALT(U/L)	794.0 (36–5538)	32.5 (7–82)
BUN (mg/dL)	13.0 (6–67)	20.0 (7–180)	T. Bil(mg/dL)	4.3 (1.4–11.8)	27.0 (7–73)
Max-BUN	70.5 (13–128)		D. Bil(mg/dL)	1.7 (0.3–10.7)	27.0 (7–73)
Cr (mg/dL)	0.7 (0.3–2)	18.0 (1–180)	PT(sec)	25.1 (15–60)	13.0 (3–31)
Max-Cr	1.8 (0.8–5.7)		PH	7.38 (7.25–7.48)	—
Na (mEq/L)	140.0 (131–153)	7.0 (2–34)	CO2 (mmHg)	36.5 (24–45)	—
K (mEq/L)	3.6 (2–6)	2.0 (2–34)	O2 (mmHg)	100.0 (40.9–221.7)	—
Ca (mg/dL)	8.1 (6–13)	7.0 (2–29)	HCO3 (mmol/L)	22.0 (13–27)	—

*Arterial blood gases; BP, blood pressure.

Table 2 Renal and liver functions tests of patients in follow-up period

Parameters	Preoperative	1 month	6 month	12 month	24 month
BUN (mg/dL)	13.5 (5–49)	30.5 (12–97)	20.0 (13–58)	14.0 (9–116)	19.0 (14–22)
Cr (mg/dL)	0.7 (0.2–1.4)	1.1 (0.4–3.1)	1.2 (0.5–2.7)	0.9 (0.5–4.7)	0.8 (0.6–0.9)
Na (mEq/L)	133.5 (125–145)	138.0 (130–143)	141.0 (131–144)	140.0 (133–146)	140.0 (136–147)
K (mEq/L)	4.2 (3.3–5.6)	4.5 (2.4–6.3)	4.4 (3.6–4.9)	4.3 (3.8–5.4)	4.0 (4–4.8)
Albumin (g/dL)	3.3 (2.3–4.4)	3.4 (2.5–4)	4.0 (3.2–4.6)	4.2 (2.9–4.6)	4.4 (4.1–4.9)
AST (U/L)	45.5 (21–172)	35.0 (15–107)	27.0 (12–81)	36.0 (0.5–83)	31.0 (20–474)
ALT (U/L)	31.0 (10–156)	50.5 (21–213)	30.0 (12–66)	18.0 (0.2–151)	52.0 (33–333)
T.Bil (mg/dL)	2.9 (0.5–39)	1.3 (0.8–22.9)	0.9 (0.52–1.85)	1.2 (0.4–34)	1.5 (1.4–2)

DISCUSSION

ARF was reported in 5% to 50% of OLT recipients[2]. ARF requiring dialysis after OLT is not uncommon; however, renal functions return to normal limits in 90% of patients[1]. Due to improved survival in these patients, end-stage renal disease (ESRD) was seen more often than previously. In our study, 2 patients had ARF requiring dialysis, and at the end of the 1 year follow-up, 1 patient had stage 4 chronic kidney disease. Hepatorenal syndrome, hepatitis C virus, and early renal failure were associated with ESRD[3],[4]. None of the patients had a history of hepatorenal syndrome or cirrhosis due to hepatitis C virus. However, 8 patients had ARF during the first 30 days of liver transplantation. In literature, it has been reported that pre- and early postoperative creatinine levels were predictive markers for ESRD[1]. Also, Fisher et al. showed that serum creatinine levels at 1 year were an independent risk factor for ESRD[5]. Creatinine levels were higher than 2 mg/dL in our 3 patients at 1 year of OLT. Posttransplant diabetes mellitus is a complication of transplantation that leads to renal insufficiency. Cyclosporine, tacrolimus, and especially steroids are responsible for diabetes mellitus[1]. Two patients had diabetes mellitus before OLT. All patients had hyperglycemia during the first month. However, during the follow-up period, none of the patients had hyperglycemia requiring insulin, except 2 patients. In the literature, it has been claimed that cyclosporine-based immunosuppression has more nephrotoxic side effects than tacrolimus in OLT[6]. Cyclosporine-based immunosuppression was used in 2 patients.

In summary, we followed 16 patients with OLT in our center. ARF developed in 8 patients. Dialysis was performed in only 2 patients, and other patients with ARF were managed with conservative measures. Hypertensive crisis and cerebrovascular stroke developed in 1 diabetic hypertensive patient. Mortality and morbidity rates were much higher in OLT recipients with ARF, especially in those with multiple organ failure. Also, ESRD can occur easily in long-term follow-up when the patients' renal functions are not well controlled.