Fahd ALMALKI, Manal E. ALOTAIBI, Mohammed Z. ABDULSATTAR, Khalid Mohammad A. AL SHUMRANI, Laila A ALHARBI, Waleed ALOTAIBI
Eurasian Journal of Medicine and Oncology - 2026;10(4):1-12
Renal dysfunction is a major determinant of morbidity, mortality, transplant candidacy, and post-transplant outcomes in cirrhosis. Acute kidney injury (AKI) develops frequently during hospitalization and is driven by circulatory dysfunction, portal hypertension, infection, gastrointestinal bleeding, diuretic exposure, nephrotoxins, and hepatorenal syndrome (HRS). Chronic kidney disease is increasingly recognized in this population and often reflects recurrent AKI, viral or alcohol-related glomerular disease, metabolic dysfunction-associated steatotic liver disease, diabetes, hypertension, or persistent renal hypoperfusion. Diagnosis remains difficult because serum creatinine underestimates renal impairment in cirrhosis. Urinalysis, renal ultrasonography, medication review, volume assessment, and selected biomarkers such as urinary neutrophil gelatinase-associated lipocalin, cystatin C, and tissue inhibitor of metalloproteinases-2/insulin-like growth factor-binding protein 7 may improve phenotyping, although biomarker-guided algorithms require further validation. Management before transplantation requires early discontinuation of nephrotoxins, careful volume resuscitation, albumin when indicated, timely treatment of infection, and vasoconstrictor therapy for HRS-AKI, with renal replacement therapy considered when standard indications arise. After liver transplantation, renal injury remains multifactorial and is influenced by pre-existing kidney disease, perioperative hemodynamic instability, ischemia-reperfusion injury, sepsis, and calcineurin inhibitor nephrotoxicity. Kidney-sparing immunosuppression, cardiovascular risk control, and structured follow-up are central to preserving renal function. Decisions regarding liver-alone transplantation, kidney-after-liver transplantation, or simultaneous liver-kidney transplantation should integrate the duration and reversibility of renal dysfunction, dialysis exposure, estimated glomerular filtration rate, and Organ Procurement and Transplantation Network Safety Net criteria. Accurate renal phenotyping across the pre- and post-transplant continuum is essential for improving survival and guiding transplant strategy.
