Authors: Mendez NV et al.
Anesthesia & Analgesia, January 26, 2026
This single-center retrospective cohort study examined the independent contribution of severe acute kidney injury (AKI) within 72 hours of liver transplantation to the subsequent development of chronic kidney disease (CKD) and long-term mortality.
Background
AKI is common following liver transplant and is associated with worse short-term outcomes. However, CKD after liver transplant is multifactorial — influenced by calcineurin inhibitor toxicity, hemodynamics, preexisting renal impairment, and perioperative events. This study aimed to quantify how much severe early postoperative AKI independently contributes to long-term CKD and mortality.
Study Design
• 1,574 adult liver transplant recipients
• Classified by presence or absence of severe AKI within 72 hours postoperatively
• Kidney function assessed at 1 year using eGFR categories:
– ≥60 mL/min/1.73 m² (normal/mild)
– 30–59 mL/min/1.73 m² (moderate CKD)
– <30 mL/min/1.73 m² (severe CKD)
Adjusted relative risks were calculated using discrete-time targeted maximum likelihood estimation — a robust causal inference method.
Key Findings
Incidence
• 49% (769 patients) developed severe AKI
• At year 1:
– 65% normal/mild CKD
– 31% moderate CKD
– 4% severe CKD
Severe CKD at 1 Year
Unadjusted relative risk:
3.66 (95% CI 2.15–7.33)
Adjusted relative risk:
2.62 (95% CI 1.61–4.28)
Severe AKI independently more than doubled the risk of severe CKD at 1 year.
Mortality
Deaths:
• Year 1: 4%
• Year 2: 7%
• Year 3: 9%
Adjusted relative risks of death in severe AKI patients:
• Year 1: 1.15
• Year 2: 1.14
• Year 3: 1.13
Although smaller than the CKD effect, severe AKI remained significantly associated with mortality up to 3 years.
Interpretation
Severe early postoperative AKI is not merely a transient complication — it serves as a major determinant of long-term renal dysfunction and survival after liver transplantation.
The strong adjusted association suggests:
• AKI likely accelerates renal trajectory toward CKD
• Early renal injury creates sustained structural or functional impairment
• AKI may amplify nephrotoxic exposures (e.g., calcineurin inhibitors)
Clinical Implications
For transplant anesthesia and perioperative teams, this study reinforces that kidney protection during liver transplant is not just about short-term dialysis avoidance, but about:
• Long-term CKD prevention
• Mortality reduction
• Graft and patient survival
Key perioperative strategies may include:
• Aggressive hemodynamic optimization
• Avoidance of sustained hypotension
• Early renal recovery strategies
• Minimization of nephrotoxic exposures
• Careful fluid balance
Key Points
• Severe AKI occurred in nearly half of liver transplant patients.
• Severe AKI doubled the risk of severe CKD at 1 year.
• Increased mortality persisted through year 3.
• AKI likely represents a modifiable perioperative target.
• Kidney protection strategies may have multiyear survival implications.
This study shifts the framing of postoperative AKI from a short-term complication to a pivotal event shaping long-term transplant outcomes.
Thank you to Anesthesia & Analgesia for allowing us to summarize and share this important work.