Department of Transplant, Mayo Clinic, Jacksonville, FL.
Department of Internal Medicine, Mayo Clinic, Jacksonville, FL.
Liver Transpl. 2019 Dec;25(12):1756-1767. doi: 10.1002/lt.25651. Epub 2019 Oct 31.
Renal dysfunction is common in liver transplantation (LT) candidates, but differentiating between reversible and irreversible renal injury can be difficult. Kidney biopsy might be helpful in differentiating reversible from irreversible renal injury, but it is associated with significant complications. We aimed to identify pre-LT predictors of potentially reversible renal injury using histological information obtained on pre-LT renal biopsy. Data on 128 LT candidates who underwent pre-LT kidney biopsy were retrospectively collected and correlated with renal histological findings. Indications for kidney biopsy were iothalamate glomerular filtration rate (iGFR) ≤40 mL/minute, proteinuria >500 mg/day, and/or hematuria. According to the biopsy diagnosis, patients were grouped into the following categories: normal (n = 13); acute tubular necrosis (ATN; n = 25); membranoproliferative glomerulonephritis (n = 19); minimal histological changes (n = 24); and advanced interstitial fibrosis (IF) and glomerulosclerosis (GS) (n = 47). Compared with patients having advanced IF/GS, patients with normal biopsies and those with ATN had lower systolic blood pressure (SBP) and diastolic blood pressure (DBP) and higher international normalized ratio and total bilirubin levels (<0.05 for all). Both SBP and DBP directly correlated with the degree of IF and GS (R = 0.3, P ≤ 0.02 for all). SBP ≤90 mm Hg was 100% sensitive and 98% specific in correlating with normal biopsies or ATN, whereas SBP ≥140 mm Hg was 22% sensitive and 90% specific in correlating with advanced IF/GS. Model for End-Stage Liver Disease score, serum creatinine, iGFR, urinary sodium excretion, and renal size did not correlate with biopsy diagnosis or degree of IF or GS. In conclusion, SBP at the time of LT evaluation correlates with renal histology, and it should be included along with other clinical and laboratory markers in the decision-making process to list patients with renal dysfunction for LT alone versus simultaneous liver-kidney transplantation.
肾功能障碍在肝移植（LT）患者中很常见，但区分可逆性和不可逆性肾损伤可能具有挑战性。肾活检可能有助于区分可逆性和不可逆性肾损伤，但它与严重的并发症有关。我们旨在通过 LT 前肾活检获得的组织学信息，确定 LT 前预测潜在可逆性肾损伤的指标。回顾性收集了 128 名接受 LT 前肾活检的 LT 候选者的数据，并将其与肾组织学发现相关联。肾活检的指征是碘酞酸盐肾小球滤过率（iGFR）≤40 mL/min、蛋白尿>500 mg/天和/或血尿。根据活检诊断，将患者分为以下几类：正常（n=13）；急性肾小管坏死（ATN；n=25）；膜增殖性肾小球肾炎（n=19）；最小组织学改变（n=24）；晚期间质纤维化（IF）和肾小球硬化（GS）（n=47）。与具有晚期 IF/GS 的患者相比，具有正常活检和 ATN 的患者的收缩压（SBP）和舒张压（DBP）较低，国际标准化比值和总胆红素水平较高（所有 P<0.05）。SBP 和 DBP 与 IF 和 GS 的程度呈直接相关（R=0.3，P≤0.02）。SBP≤90 mmHg 在相关性上 100%敏感且 98%特异，而 SBP≥140 mmHg 在相关性上 22%敏感且 90%特异，与晚期 IF/GS 相关。终末期肝病模型评分、血清肌酐、iGFR、尿钠排泄和肾脏大小与活检诊断或 IF 或 GS 的程度均不相关。总之，LT 评估时的 SBP 与肾组织学相关，并且应该与其他临床和实验室标志物一起纳入决策过程，以决定将肾功能障碍患者单独列为 LT 还是同时进行肝-肾移植。
