Confronting the Growing Challenge of Preserving Renal Function Following Liver Transplantation

Faculty

Needs Statement

As patient and graft survival after liver transplantation continues to improve, unmet medical needs have emerged as a focus of concern for clinicians involved in long-term patient management.  Pre- and post-transplant renal dysfunction represents one of the most serious challenges facing liver transplantation today.  Acute and chronic renal failure, occurring both before and after liver transplantation, complicates patient management and has been associated with increased morbidity and mortality.
 
Renal function is an integral component in the calculation of the MELD score.  As a result, in addition to prioritizing patients with more severe liver diseases, MELD also prioritizes patients with worse pre-transplant kidney function.  Not surprisingly, MELD implementation has contributed to the increase in the number of patients requiring preoperative renal replacement. Acute renal failure occurs frequently, but with highly variable incidence (12-64%) following liver transplantation. O’Riordan and colleagues observed a significant decrease in patient survival at 30 days and 1 year after liver transplant in patients who developed acute renal failure as compared to those with normal renal function (30 days: 76.3% vs. 95.7%, p<0.001; 1 year: 47.5% vs. 78.4%, p<0.001). Development of acute renal failure also increased length of hospital stay.  Consequently, the implications of avoidance of acute renal failure after liver transplantation on patient outcomes are significant.
 
Liver transplant patients are also at risk for development of chronic renal failure.  With the exception of recipients of intestinal transplants, liver transplant recipients have the highest 5 year incidence of chronic renal failure of any non-renal solid organ transplant.6 Herlenius and colleagues observed a nearly 30% decline in glomerular filtration rate during the first 3 months post transplant. The cumulative incidence of chronic renal failure increases with time after liver transplantation, reaching a peak of nearly 20% at 5 years. Liver transplant recipients who develop chronic renal failure are at a 4.5-fold increased risk of death compared to those without chronic renal failure.6  Chronic renal failure after liver transplant is multi-factorial in etiology, but nephrotoxicty associated with calcineurin inhibitors plays a major role.
The recognition that both acute and chronic kidney disease after liver transplantation is relatively common and associated with greater mortality underscores the magnitude of the need to identify patients at risk and to develop strategies minimize its short and long-term impact.  Early intervention in patients at risk may offer valuable opportunities for long-term preservation of renal function.

Target Audience

This activity is intended for surgeons, physicians, and pharmacists involved in the care of solid organ transplant recipients.

 

Objectives

1. Discuss the impact of renal failure on patient outcome after liver transplantation;
2. Describe risk factors for the development of renal failure after liver transplantation;
3. Identify strategies to reduce the risk of development chronic renal failure after liver transplantation.

Accreditation

CME
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the University of Kentucky College of Medicine and CTI Clinical Trial & Consulting Services. The University of Kentucky College of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

The University of Kentucky College of Medicine designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The University of Kentucky College of Medicine presents this activity for educational purposes only. Participants are expected to utilize their own expertise and judgment while engaged in the practice of medicine. The content of the presentations is provided solely by presenters who have been selected for presentations because of recognized expertise in their field.

CPE
The University of Kentucky College of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

This knowledge-based activity has been assigned ACPE # 022-999-09-052-H01-P and will award 1.00 contact hour (0.1 CEU) of continuing pharmacy education credit in states that recognize ACPE providers.

Statements of credit will indicate hours and CEUs based on participation and will be issued online at the conclusion of the activity. Successful completion includes completing the activity, its accompanying evaluation and/or posttest (score 70% or higher) and requesting credit online at the conclusion of the activity. The College complies with the Accreditation Standards for Continuing Pharmacy Education.

Faculty Disclosure

Dr. Charlton has no relationship to disclose.
Dr. Davis has received contract research support from Astellas and Roche.
Dr. Garcia-Valdecasas has no relationship to disclose.

 

Activity Sponsorship

This activity is jointly sponsored by the University of Kentucky and CTI Clinical Trial & Consulting Services. Supported by an unrestricted educational grant from Bristol-Myers Squibb.