How to prevent chronic kidney disease after liver transplantation?

Risk factors contributing to chronic kidney disease (CKD) after liver transplantation (LT) are multifaceted, involving episodes of acute kidney injury (AKI), donor-related factors, and immunosuppressive medication, notably calcineurin inhibitors (CNIs).AKI is a common complication post-LT, affecting nearly half of all patients, with approximately 15% requiring kidney replacement therapy.Recipient factors such as metabolic syndrome, diabetes, obesity, age, ethnicity, hepatitis C infection, and prior malignancy contribute to post-transplant CKD.Maintenance immunosuppressive regimens, particularly early CNI administration, may exacerbate CKD progression by inducing chronic vasoconstriction of kidney arterioles.Early detection of risk factors, addressing modifiable ones, and minimizing perioperative AKI are essential focuses for high-risk individuals.Prioritizing strategies targeting CKD management, diabetes, and hypertension, along with the utilization of Kidney Disease Improving Global Outcomes (KDIGO) recommendations, is crucial for effective management.Blood pressure targets, pharmacological interventions, and timely referral to nephrologists for access creation are integral components of CKD management.Additionally, optimization of immunosuppressive protocols, primarily through CNI minimization or withdrawal, and considering alternative agents like mammalian target of rapamycin (mTOR) inhibitors or antimetabolites, play pivotal roles in preserving renal function.Adjusting the immunosuppressive regimen, particularly by minimizing CNIs in the first post-transplant year, can slow kidney dysfunction progression.Identifying and addressing risk factors for renal dysfunction, optimizing perioperative care, and tailoring immunosuppressive regimens are essential steps to enhance long-term outcomes following LT.