Sessa C, Gembillo G, Morale W. Rethinking chronic kidney disease risk after liver transplantation. World J Transplant 2026; 16(2): 115035 [DOI: 10.5500/wjt.v16.i2.115035]
Corresponding Author of This Article
Concetto Sessa, MD, Department of Nephrology and Dialysis, Maggiore “Nino Baglieri” Hospital, Via Aldo Moro 1, 97015 Modica (RG), Sicily, Italy. concettosessa@gmail.com
Research Domain of This Article
Medicine, Research & Experimental
Article-Type of This Article
editorial
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World J Transplant. Jun 18, 2026; 16(2): 115035 Published online Jun 18, 2026. doi: 10.5500/wjt.v16.i2.115035
Rethinking chronic kidney disease risk after liver transplantation
Concetto Sessa, Guido Gembillo, Walter Morale
Concetto Sessa, Walter Morale, Department of Nephrology and Dialysis, Maggiore “Nino Baglieri” Hospital, 97015 Modica (RG), Sicily, Italy
Guido Gembillo, Department of Clinical and Experimental Medicine, Unit of Nephrology and Dialysis, University of Messina, Messina 90125, Italy
Co-first authors: Concetto Sessa and Guido Gembillo.
Author contributions: Gembillo G and Morale W were responsible for the conception of the study and supervision; Gembillo G and Sessa C were responsible for the design, the writing, the literature review, and the critical review of the manuscript; they contributed equally to this article, and they are the co-first authors of this manuscript. All authors thoroughly reviewed and endorsed the final manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Concetto Sessa, MD, Department of Nephrology and Dialysis, Maggiore “Nino Baglieri” Hospital, Via Aldo Moro 1, 97015 Modica (RG), Sicily, Italy. concettosessa@gmail.com
Received: October 9, 2025 Revised: December 11, 2025 Accepted: January 19, 2026 Published online: June 18, 2026 Processing time: 235 Days and 15.6 Hours
Abstract
In this editorial, we comment on the article by Muñoz-Serrano et al published in the World Journal of Transplantation. Chronic kidney disease (CKD) is one of the most frequent and severe complications after liver transplantation (LT), threatening long-term survival beyond graft-related issues. Its pathogenesis is multifactorial, combining calcineurin inhibitor (CNI) nephrotoxicity with pre- and perioperative renal insults and metabolic comorbidities. We reviewed recent evidence from clinical trials, meta-analyses, and practice guidelines evaluating risk factors and management of CKD after LT, with a focus on immunosuppression strategies, perioperative care, and prognostic determinants. CKD develops in approximately 30% of LT recipients at 1 year and exceeds 40% at 5 years, with stage G3 predominating. Key predictors of post-LT CKD include high pre-LT creatinine [odds ratio (OR) = 7.74], early post-LT acute kidney injury (OR = 2.72), hypertension (OR = 4.833), and metabolic dysfunction-associated steatotic liver disease, including non-alcoholic steatohepatitis, as the underlying etiology. Tacrolimus remains superior to cyclosporine in overall survival and hypertension control, though hypomagnesemia and diabetogenicity are clinically relevant toxicities. CNI minimization - through basiliximab induction, low-dose tacrolimus with mycophenolate, or everolimus conversion - improves renal outcomes without compromising graft survival, despite trade-offs such as mild acute rejection or higher malignancy rates. CKD at 1 year confers a 4.48-fold increase in mortality risk, underscoring the prognostic weight of renal preservation. Renal protection after LT requires systematic preoperative risk stratification, perioperative CNI minimization, individualized immunosuppression, and aggressive metabolic management. Future integration of non-invasive biomarkers, including kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin, together with standardized simultaneous liver-kidney transplantation criteria, may further refine patient-tailored nephroprotection strategies. Muñoz-Serrano et al retrospectively analyzed 594 liver transplant recipients over three decades to identify risk factors for CKD at one year post-transplant. The authors identified older age, female sex, pre-transplant renal dysfunction, and treatment with cyclosporine A as independent risk factors.
Core Tip: Chronic kidney disease following liver transplantation is a critical, modifiable determinant of long-term survival. Its pathogenesis extends beyond calcineurin inhibitor (CNI) toxicity to include pre-transplant renal dysfunction, perioperative acute kidney injury, and metabolic comorbidities like hypertension. Consequently, shifting focus toward early nephroprotection is essential. Evidence supports a multi-pronged approach: proactive perioperative hemodynamic management, the use of basiliximab induction to safely delay CNI exposure, mycophenolate-based CNI minimization, and aggressive metabolic control. These strategies significantly enhance long-term renal preservation without compromising graft integrity.
