Difficulties in diagnosing acute kidney injury post liver transplantation using serum creatinine based diagnostic criteria

Abstract

Renal function in patients with advanced cirrhosis is an important prognostic factor for survival both prior to and following liver transplantation. The importance of renal function is reflected by the introduction of the model for end stage liver disease (MELD) score, which includes serum creatinine. The MELD score has been shown to predict the short term risk of death for transplant wait listed patients and is currently used by many countries to allocate liver transplants on the basis of severity of underlying illness. Changes in serum creatinine are also used to stage acute kidney injury. However prior to liver transplantation the serum creatinine typically over estimates underlying renal function, particularly when a colorimetric Jaffe based assay is used, and paradoxically then under estimates renal function post liver transplantation, particularly when immunophyllins are started early as part of transplant immunosuppression. As acute kidney injury is defined by changes in serum creatinine, this potentially leads to over estimation of the incidence and severity of acute kidney injury in the immediate post-operative period.

Keywords: Serum creatinine; Acute kidney injury; Liver transplantation

Core tip: Acute kidney injury is defined and severity graded based on changes in serum creatinine. Increasing concentrations of bilirubin interefere with laboratory determination of creatinine and reduce creatinine estimations. Post transplantation serum creatinine increases due to a combination of fall bilirubin and the loading doses of calcineurin inhibitor immunosupressants. This combination leads to an over estimation of the lesser grades of acute kidney injury post liver transplantation.