gms | German Medical Science

Einleitung: Acute renal failure (ARF) is a relevant and frequent complication after liver transplantation (LTx). Renal function has immediately after LTx and also during the further course a basic influence on the quality of life and the survival rate of transplant recipients. Thus we analyzed LTx recipients who had developed an ARF in the early postoperative course (up to and including POD 7).

Material und Methoden: Between 1988 and 2001, a total umber of 1.352 patients underwent LTx at the Department of Transplant Surgery Charité Berlin. This collective was followed in a retrospective analysis with regard to the incidence, etiology, therapy and outcome of ARF. An ARF was defined once the calculated GFR (Cockroft-Gault, MDRD) decreased >50% or the serum creatinine doubled above 2.5 mg/dl within the first week after LTx. Patients with a hepatorenal syndrome (HRS) type I pre-LTx were excluded from the study.

Ergebnisse: A total of 162 patients developed an ARF within the first week after LTx (11.9%). Patients had a mean age of 53.7 years; 89 of 162 were men. Duration of chronic disease leading to LTx was 36 to 469 months. Overall 5-year patient/graft survival rates were 89.4/82%. 162 recipients with ARF had the following indications for LTx: alcoholic cirrhosis (n=68); primary biliary cirrhosis, primary sclerosing cholangitis, autoimmunehepatitis (n=23); hepatitis B related liver cirrhosis (n=19); hepatitis C or NANB hepatitis (n=31); others (n=21). In the majority the cause of ARF was due to a multifactorial genesis, whereas approximately half of the patients (n=83; 51%) had a chronic renal insufficiency (stage I-III) within the scope of a HRS type II with a GFR 50-35 ml/min. Mean kindey-data pre-LTx were: GFR 63 ml/min (± 29 ml/min), creatinine/BUN 1.6/73 mg/dl (± 0.5/21 mg/dl) and post-LTx until POD 7: GFR 18 ml/min (± 13 ml/min), creatinine/BUN 2.7/158 mg/dl (± 0.8/38 mg/dl). None of the patients died during study period and a total of 157 patients (97%) were recompensated (GFR >50 ml/min; creatine <2.5 mg/dl) at POD 28. Altogether 52 patients (32%) received on average 6 hemodialysis treatments (range: 2-17); excluded those 5 patients (3%) who developed endstage renal failure (ERF). Patients who needed a temporary renal replacement therapy showed pre-LTx: GFR 48 ml/min (± 18 ml/min), creatinine/BUN 1.9/82 mg/dl (± 0.6/37 mg/dl) whereas patients with an ARF leading to ERF had a pre-LTx GRF of only 28 ml/min; diagnosis of those were hepatitis C (n=3), alcoholic cirrhosis and others (n=2). Therapy of ARF consists of fluid replacement, reduction/adaptation of the immunosuppressive therapy, avoiding exposure to nephrotoxic drugs and adjusted dosages and - if necessary - renal replacement therapy.

Schlussfolgerung: In summary the ARF after LTx showed a good prognosis with a recompensation rate of 97% within 4 weeks after surgery. Since multifactorial genesis is the most frequent cause of ARF there are 2 major risk factors leading to ARF after LTx: this is a creatinine above 1.5 mg/dl and GFR <50 ml/min. And if one looks on those 3% developing an ERF after LTx there seems to be 3 risk factors: a hepatorenal syndrome type II with GFR <30 ml/min and the diagnosis of hepatitis C. To be able to identify this in advance and to apply an optimal adjusted immunosuppressive- and drug therapy can have a significant importance on the outcome of this selected collective of liver transplant recipients.