Acute kidney injury (AKI) is a common condition following liver transplantation (LT). It negatively impacts patient outcomes by increasing the chances of developing chronic kidney disease (CKD) and reducing graft and patient survival. Multiple definitions of AKI have been proposed and utilized throughout the years with the International Club of Ascites (ICA) definition being the most widely used now for cirrhosis patients. Multiple factors are associated with development of post-LT AKI and can be categorized into pre-LT comorbidities, donor and recipient characteristics, operative factors, and post-LT factors. Many of these factors can be optimized in an attempt to minimize the risk of AKI occurring and to improve renal function if AKI is already present. A special consideration during the post-LT phase is need for immunosuppression as certain immunosuppressive medications can be nephrotoxic. The calcineurin inhibitor (CNI) tacrolimus is the mainstay of immunosuppression but can result in AKI. Several strategies including use of the monoclonoal antibody basilixamab to allow for delayed tacrolimus start and minimization or elimination of tacrolimus through combination with mycophenolate mofetil (MMF) or mammalian target of rapamycin (mTOR) inhibitors have been implemented to reverse and avoid AKI in the post-LT setting. Renal replacement therapy may ultimately be required to support patients until recovery of AKI post-LT. Overall by improving renal function in post-LT patients with AKI, outcomes can be improved.
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