LT candidates with proteinuria and renal dysfunction are often considered for SLK. Methods: 39 LT candidates with 24-hr urine protein >150 mg/dl and renal dysfunction (defined as iothalamate GFR<40 ml/min or dialysis) underwent percutaneous kidney biopsy. Patients with ≥30% interstitial fibrosis (IF) or ≥30% glomerulosclerosis (GS) were listed for SLK. Prior to biopsy, INR and platelet count were maintained <1.5 and >50,000/ml, respectively, using fresh frozen plasma and platelet transfusion. Patients were monitored overnight for post-biopsy bleeding. Results: At time of biopsy 3 patients were on dialysis and the mean±SD GFR for the remaining 36 was 30±15 ml/min. The median (range) 24-hr urine protein was 741 (155-13,625) mg/day. Based on biopsy findings, 19 and 20 patients were listed for LT and SLK, respectively. Characteristics of these patients are presented in table.

4 patients (10%) had post-biopsy bleeding, of these 2 required selective embolization. After a median (range) 209 (31-1020) days from biopsy, 14 and 11 patients received LT and SLK, respectively. After 1.9±1.6 years of post-tx follow-up, creatinine (1.4±0.5 vs 1.3±0.5 mg/dl, P=0.6) and the risk of ESRD (figure) were comparable between LTA and SLK recipients

Conclusions: 1) Almost 50% of LT candidates with renal dysfunction and proteinuria have reversible renal histology. 2) Clinical, laboratory and radiological findings do not differentiate between reversible and irreversible renal injury. 3) 10% of LT candidates develop kidney biopsy related bleeding 4) Kidney allocation based on biopsy findings leads to comparable renal recovery rate following LT and SLK.

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