A non-induction renal sparing approach after liver transplantation: High dose mycophenolate mofetil with delayed, low-dose tacrolimus

Background: Approaches to preserve renal function after liver transplantation (OLT), such as the delayed use of calcineurin inhibitors (CNI), may reduce the need for postoperative renal replacement therapy (RRT) or simultaneous liver-kidney transplantation (SLK). Methods: An 1:1 analysis was performed comparing 1-year outcomes of patients with pre-OLT renal dysfunction receiving a renal-sparing approach (RS): MMF (3 g/d), steroids, and delayed tacrolimus (TAC) (day 3 post-OLT; trough, 5-8 ng/mL) versus SLK: MMF (2 g/d), steroids, and immediate TAC (trough 10-12 ng/mL). Results: In 84 OLT recipients (42 RS, 42 SLK) Model for End-Stage Liver Disease and creatinine were similar at OLT, with improved creatinine at 1 year (all P <.01 from OLT). Patient survival, graft function, infection, and rejection were similar at 1 year (P >.05). However, the RS patients had a higher rate of death in those requiring preoperative RRT (7/10 RRT vs 5/32 no RRT; P <.001). Of the patients on preoperative RRT, more RS patients continued to require postoperative RRT than SLK (7/10 vs 5/17; P =.04), of which there was a comparably higher death rate than those not needing postoperative RRT. Conclusion: This noninduction, RS protocol is effective in patients not on pre-OLT RRT. Patients on RRT pre-OLT should be considered for more aggressive renal sparing approaches (induction therapy with more delayed CNI initiation or SLK).