Posttransplant Chronic Kidney Disease Research Articles

Incidence and Risk Factors Associated With Chronic Kidney Disease After Liver Transplantation: A Review of a 20-Year Experience at a Single Center

Chronic kidney disease (CKD) is one of the major complications after liver transplantation (LT), with a significant impact on patient outcomes. This study aims to investigate the incidence and risk factors of CKD in LT recipients at Siriraj Hospital over the past 20 years. There were 366 adult patients undergoing LT at Siriraj Hospital between January 2002 and December 2021. After excluding patients with pretransplant CKD stages 4 to 5, simultaneous liver-kidney transplantation, and patients who died after LT within 90 days, we retrospectively reviewed a total of 288 patients. Univariable and multivariable binary logistic regression analyses were used to identify the risk factors of post-transplant CKD. Of the 288 patients, 171 (59.4%) developed CKD after LT. The median time to develop CKD was 5.8 months (IQR, 3.8-15.3). Univariable and multivariable analyses revealed that age ≥55 years (odds ratio [OR] = 2.44; 95% CI, 1.34-4.42; P = .003), pretransplant kidney dysfunction defined as estimated glomerular filtration rate <60 mL/min/1.73 m2 (OR = 2.23; 95% CI, 1.16-4.27; P = .016), and postoperative acute kidney injury (OR = 3.06; 95% CI, 1.73-5.42; P < .001) were significantly associated with post-transplant CKD. Patients with preexisting kidney dysfunction who received delayed calcineurin inhibitor introduction without antibody induction protocol had a significantly lower incidence of post-transplant CKD (OR = 0.28; 95% CI, 0.11-0.70; P = .007). Advanced age, pre-transplant kidney dysfunction, and postoperative acute kidney injury are risk factors for CKD after LT. Importantly, delayed calcineurin inhibitor introduction can protect patients with pretransplant kidney dysfunction from developing post-transplant CKD. These results may have important clinical implications in reducing the incidence of CKD after LT.

Effect of the response to preoperative treatment for hepatorenal syndrome on the outcome of recipients of living-donor liver transplantation.

The effect of pretransplant hepatorenal syndrome (HRS) on the outcomes of living-donor liver transplantation (LDLT) recipients with special reference to the recovery of HRS before LDLT was investigated. The rate of HRS was 43.9% (125/285) among the cohort, and the subjects were divided into three groups: those without HRS (No-HRS group, n=160), those with HRS but recovered following pretransplant renal function restoration treatment (Responders group, n=55), and those with persistent HRS (Non-responders group, n=70). While the 1-, 3-, and 5-year patient survival rates were comparable between those with and without HRS (89.6%, 84.7%, and 84.7% vs 95.6%, 92.2%, and 87.5%), the cumulative incidence of the development of posttransplant chronic kidney disease (CKD) was significantly higher in those with HRS (P < .001). In addition, there was a significant difference between Responders and Non-responders in the development of CKD (P=.01). In the Cox regression model, Non-responders (P=.032, HR 1.79 [95% C.I. 1.05-3.03]) and recipient age (P=.014, HR 1.62 [95% C.I. 1.10-2.37]) were independent predictors for the development of CKD after LDLT. Living-donor liver transplantation is safe and effective for patients with HRS, and CKD progression could be reduced among those with HRS who responded to renal restoration treatment.

Peri-operative risk factors of chronic kidney disease after liver transplantation

Chronic kidney disease (CKD) is a frequent long-term complication after liver transplantation (LT) and is associated with poor long-term survival. The aim of our study was to identify the risk factors of developing post-transplant CKD at 1 year, during the pre-operative, peri-operative, and post-LT phases. All consecutive patients who underwent primary LT between July 2013 and February 2018 were analyzed. To assess the impact of peri- and post-operative factors on renal function at 1 year we performed a propensity score matching on gender, age of the recipient, Model for End-Stage Liver Disease (MELD) score, etiology of the hepatic disease, and estimated Glomerular Filtration Rate (eGFR) at baseline. Among the 245 patients who underwent LT, 215 had available data at one year (Y1), and 46% of them had CKD. Eighty-three patients in the CKD group and 83 in the normal renal function group were then matched. The median follow-up was 35months (27-77). Patients with CKD at Y1 had a decreased 5-year survival compared to patients with normal renal functionat one year: figures were62% and 90%, respectively, p = 0.001. The independent predictors of CKD at Y1 were major complications (OR = 2.2, 95% CI [1.2-4.2]), p = 0.015, intensive care unit (ICU) stay > 5days (OR = 2.2, 95% CI [1.3-5.1]), p = 0.046, ICU serum lactate level at 24h ≥ 2.5mmol/L (OR = 3.8 95% CI [1.1-8]), p = 0.034, need forpost-LT renal replacement therapy (OR = 6.4 95% CI [1.4-25]), and MELD score ≥ 20 (OR = 2.1 95% CI [1.1-3.9]), p = 0.019. The peri-operative period has a major impact on CKD incidence. Early recognition of patients at high risk of CKD may becritical for implementation of nephroprotective measures.

Pre-Transplant Obesity and Post-Transplant Chronic Kidney Disease: Time-Dependent Effect of Kidney Transplantation

ObjectivesObesity is associated with worsening kidney allograft function. Since kidney allograft function may rapidly change throughout the course of kidney transplantation, particularly during early post-transplant period, we aim to examine association between pre-transplant obesity and development of chronic kidney disease (CKD) over several time points during post-transplant periods. MethodsA single center retrospective cohort study included kidney transplant recipients who received kidney transplantation, between 2012 and 2015. The study population were divided into non-obese and obese groups based on pre-transplant body mass index (BMI) of < 30 and ≥30 kg/m2, respectively. Association between the obesity status and post-transplant CKD defined as estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2 was examined by multivariable Cox proportional hazard regression analysis with a time-dependent effect at 12, 24, 36, and 48 weeks post-kidney transplantation. ResultsOf all 105 patients, mean age ± SD was 54 ± 12 and 61% was female. Non-obese and obese groups were account for 64% and 36%, respectively and their corresponding mean BMI were 24.34 ± 3.54 and 34.27 ± 3.53 kg/m2 (P < 0.001). The risk of developing CKD at 12, 36, and 48 weeks post-kidney transplantation, were not significantly difference. However, at 24-week post- kidney transplantation, obese group had 71% greater the risk for CKD compared to non-obese group (Hazard ratio (HR) 1.71, P 0.049, 95% confidence interval (95%CI) 1.002, 2.908). After adjusted for age, gender, type of kidney transplantation, systolic and diastolic blood pressure at 24 weeks post-kidney transplantation, the obese group remain at higher the risk for CKD (HR 1.74, P 0.044, 95% CI 1.014, 2.985). ConclusionsPre-kidney transplant obesity was associated with increased risk of CKD at the early, but not at the immediate or long-term post-transplant periods independent to the baseline characteristics and blood pressure. Pathophysiological changes during different post-transplant periods including immunological or non-immunological factors may contribute to this time-dependent effects of pre-transplant obesity and CKD. Additional studies are warranted to further examine possible mechanism. Funding SourcesNone.

Detection of pro angiogenic and inflammatory biomarkers in patients with CKD

Cardiovascular disease (CVD) is the most common cause of death in patients with native and post-transplant chronic kidney disease (CKD). To identify new biomarkers of vascular injury and inflammation, we analyzed the proteome of plasma and circulating extracellular vesicles (EVs) in native and post-transplant CKD patients utilizing an aptamer-based assay. Proteins of angiogenesis were significantly higher in native and post-transplant CKD patients versus healthy controls. Ingenuity pathway analysis (IPA) indicated Ephrin receptor signaling, serine biosynthesis, and transforming growth factor-β as the top pathways activated in both CKD groups. Pro-inflammatory proteins were significantly higher only in the EVs of native CKD patients. IPA indicated acute phase response signaling, insulin-like growth factor-1, tumor necrosis factor-α, and interleukin-6 pathway activation. These data indicate that pathways of angiogenesis and inflammation are activated in CKD patients’ plasma and EVs, respectively. The pathways common in both native and post-transplant CKD may signal similar mechanisms of CVD.

Independent risk factors and long-term outcomes for acute kidney injury in pediatric patients undergoing hematopoietic stem cell transplantation: a retrospective cohort study

BackgroundAcute kidney injury (AKI) remains a frequent complication in children undergoing hematopoietic stem cell transplantation (HSCT) and an independent risk factor of the patient’s survival and a prognostic factor of progression to chronic kidney disease (CKD). However, the causes of these complications are diverse, usually overlapping, and less well understood.MethodsThis retrospective analysis was performed in 43 patients (28 boys, 15 girls; median age, 5.5 years) undergoing HSCT between April 2006 and March 2019. The main outcome was the development of AKI defined according to the Pediatric Risk, Injury, Failure, Loss, End-stage Renal Disease (pRIFLE) criteria as ≥ 25% decrease in estimated creatinine clearance. The secondary outcome was the development of CKD after a 2-year follow-up.ResultsAKI developed in 21 patients (49%) within 100 days after HSCT. After adjusting for possible confounders, posttransplant AKI was associated with matched unrelated donor (MUD) (HR, 6.26; P = 0.042), but not total body irradiation (TBI). Of 37 patients who were able to follow-up for 2 years, 7 patients died, but none had reached CKD during the 2 years after transplantation.ConclusionsPosttransplant AKI was strongly associated with HSCT from MUD. Although the incidence of AKI was high in our cohort, that of posttransplant CKD was lower than reported previously in adults. TBI dose reduced, GVHD minimized, and infection prevented are required to avoid late renal dysfunction after HSCT in children since their combinations may contribute to the occurrence of AKI.

Risk Factors for Acute Kidney Injury and Chronic Kidney Disease following Allogeneic Hematopoietic Stem Cell Transplantation for Hematopoietic Malignancies

Background: Acute kidney injury (AKI) and chronic kidney disease (CKD) are considered common complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Objectives and Method: In this study, 114 patients who had undergone allo-HSCT were retrospectively analyzed to investigate the risk factors for onset of posttransplant AKI and CKD as defined by the new Kidney Disease Improving Global Outcomes criteria. Results: Seventy-four patients (64.9%) developed AKI and 25 (21.9%) developed CKD. The multivariate analysis showed that the risk factors for developing stage 1 or higher AKI were age ≥46 years at the time of transplant (p = 0.001) and use of ≥3 nephrotoxic drugs (p = 0.036). For CKD, the associated risk factors were disease status other than complete remission at the time of transplantation (p = 0.018) and onset of AKI after transplant (p = 0.035). The 5-year overall survival (OS) was significantly reduced by development of AKI (p < 0.001), but not CKD. Posttransplant AKI significantly increased the 5-year nonrelapse mortality (p < 0.001), whereas posttransplant CKD showed an increasing tendency, but the difference was not significant. Conclusions: Posttransplant AKI impacts OS, significantly increases the risk of CKD, and is significantly associated with disseminated intravascular coagulation and use of ˃3 nephrotoxic drugs.

Novel educational and goal-setting tool to improve knowledge of chronic kidney disease among liver transplant recipients: A pilot study.

IntroductionLiver transplant (LT) recipients have limited understanding of post-transplant chronic kidney disease (CKD) despite an excellent pre-existing framework of transplant care. This pilot study examined the efficacy and feasibility of a tailored educational and goal-setting tool in improving CKD knowledge among LT recipients with early-stage CKD.MethodsIn this prospective cohort study, we administered the CKD educational and goal-setting tool to 81 LT recipients between 7/1/2016 and 12/31/2017. We excluded patients with simultaneous liver-kidney transplantation, eGFR<30 ml/min, non-English speaking, on hemodialysis or listed for kidney transplantation. The pre- and post-education knowledge scores were compared using a paired t-test. Linear regression was used to assess the independent predictors of change in knowledge score.ResultsMean age was 56.3 years, 69.1% were males, 85.2% were Caucasians and mean eGFR was 61.2 ± 20.0 ml/min. The CKD educational and goal-setting tool improved the CKD knowledge scores among LT recipients (pre: 71.8 ± 16.6%, post: 83.3 ± 10.4%; p<0.001). In an adjusted model (r2 = 0.75), those with lower pre-education knowledge scores had the most improvement in their post-education knowledge scores (β = -83.2; p<0.001). Two-thirds stated their most important self-management goal and reported motivation to follow this goal. Time spent for the CKD education was approximately 15 minutes.ConclusionsA simple LT-specific patient educational and goal-setting tool effectively improved CKD knowledge. Implementation of this tailored intervention will improve CKD awareness and may promote goal-setting in the target population.

Acute Kidney Injury After Liver Transplantation.

Since the implementation of the Model of End-stage Liver Disease score-based allocation system, the number of transplant candidates with impaired renal function has increased. The aims of this review are to present new insights in the definitions and predisposing factors that result in acute kidney injury (AKI), and to propose guidelines for the prevention and treatment of postliver transplantation (LT) AKI. This review is based on both systematic review of relevant literature and expert opinion. Pretransplant AKI is associated with posttransplant morbidity, including prolonged post-LT AKI which then predisposes to posttransplant chronic kidney disease. Prevention of posttransplant AKI is essential in the improvement of long-term outcomes. Accurate assessment of baseline kidney function at evaluation is necessary, taking into account that serum creatinine overestimates glomerular filtration rate. New diagnostic criteria for AKI have been integrated with traditional approaches in patients with cirrhosis to potentially identify AKI earlier and improve outcomes. Delayed introduction or complete elimination of calcineurin inhibitors during the first weeks post-LT in patients with early posttransplant AKI may improve glomerular filtration rate in high risk patients but with higher rates of rejection and more adverse events. Biomarkers may in the future provide diagnostic information such as etiology of AKI, and prognostic information on renal recovery post-LT, and potentially impact the decision for simultaneous liver-kidney transplantation. Overall, more attention should be paid to pretransplant and early posttransplant AKI to reduce the burden of late chronic kidney disease.

Post-transplant Renal Function and Cardiovascular Events Are Closely Associated With the Aortic Calcification Index in Renal Transplant Recipients

IntroductionThe aortic calcification index (ACI) is reported to be closely associated with renal dysfunction and cardiovascular events; however, its implication in renal transplant recipients has not been well examined. In this study, we investigated the relationship between pretransplant ACI, ACI progression, post-transplant renal function, and post-transplant cardiovascular events in renal transplant recipients. Patients and methodsThe study from June 1996 to Jan 2012 included 61 renal transplant recipients (living donors, 47; cadaveric donors, 14). The median follow-up period was 60 months. ACI was quantitatively measured on abdominal computed tomography. The relationship between age, dialysis period, estimated glomerular filtration rate (eGFR), and pre- and post-transplant ACI was longitudinally evaluated. Risk factors for post-transplant ACI progression were determined by logistic regression analysis. Patient background and the incidence of post-transplant cardiovascular events were also assessed. ResultsThe pretransplant ACI (median 4.2%) significantly correlated with age at transplant, dialysis period, and diabetes mellitus. ACI gradually increased up to 2.8 times at 10 years after transplantation. Post-transplant eGFR significantly correlated with ACI progression in patients with chronic kidney disease of stage ≥3. Logistic regression analyses showed that age at transplantation, post-transplant period, cadaveric donors, and post-transplant chronic kidney disease stage 3 were risk factors for post-transplant ACI progression. The pretransplant ACI was higher (median 66%) in 3 patients who experienced post-transplant cardiovascular events. ConclusionsACI progression closely correlates with age and post-transplant renal function. A high pretransplant ACI is a risk factor for post-transplant cardiovascular events in renal transplant recipients.

Chronic kidney disease after liver transplantation in human immunodeficiency virus/hepatitis C virus-coinfected recipients versus human immunodeficiency virus-infected recipients without hepatitis C virus: Results from the national institutes of health mu

Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) are both associated with chronic kidney disease (CKD), a major complication after orthotopic liver transplantation (OLT). The aim of this study was to assess predictors of post-OLT CKD in HIV/HCV-coinfected recipients versus HIV-infected recipients without HCV (HIV/non-HCV recipients). Data from a National Institutes of Health study of 116 OLT recipients (35 HIV/non-HCV recipients and 81 HIV/HCV-coinfected recipients) from 2003 to 2010 (Solid Organ Transplantation in HIV: Multi-Site Study) were analyzed for the pretransplant CKD prevalence [estimated glomerular filtration rate (eGFR) < 60 mL/minute for ≥3 months] and the incidence of CKD up to 3 years posttransplant. Proportional hazards models were performed to assess predictors of posttransplant CKD. A contemporaneous cohort of HCV-monoinfected transplant recipients from the Scientific Registry of Transplant Recipients database was also analyzed. The median age at transplant was 48 years, the median serum creatinine level was 1.1 mg/dL, and the median eGFR was 77 mL/minute. Thirty-four patients were suspected to have pretransplant CKD; 20 of these patients (59%) had posttransplant CKD. Among the 82 patients without pretransplant CKD (26 HIV/non-HCV patients and 56 HIV/HCV-coinfected patients), the incidence of stage 3 CKD 3 years after OLT was 62% (55% of HIV/non-HCV patients and 65% of HIV/HCV-coinfected patients), and the incidence of stage 4/5 CKD was 8% (0% of HIV/non-HCV patients and 12% of HIV/HCV-coinfected patients). In a multivariate analysis, older age [[hazard ratio (HR) = 1.05 per year, P = 0.03] and the CD4 count (HR = 0.90 per 50 cells/μL, P = 0.01) were significant predictors of CKD. HCV coinfection was significantly associated with stage 4/5 CKD (HR = 10.8, P = 0.03) after adjustments for age. The cumulative incidence of stage 4/5 CKD was significantly higher for HIV/HCV-coinfected patients versus HIV/non-HCV transplant recipients and HCV-monoinfected transplant recipients (P = 0.001). In conclusion, CKD occurs frequently in HIV-infected transplant recipients. Predictors of posttransplant CKD include older age and a lower posttransplant CD4 count. HCV coinfection is associated with a higher incidence of stage 4/5 CKD. Liver Transpl 19:619–626, 2013. © 2013 AASLD.

Chronic Kidney Disease After Orthotopic Liver Transplantation: Impact of Hepatitis C Infection

Hepatitis C virus (HCV) infection has been shown to be a potential risk factor for the development of chronic kidney disease in liver transplant recipients. We performed a retrospective cohort study of 307 patients with and without HCV cirrhosis and preserved pretransplant renal function (serum creatinine<1.5 mg/dL pretransplantation) to assess the impact of HCV on the incidence of posttransplant chronic kidney disease. Kaplan-Meier analysis was performed for time to development of estimated glomerular filtration rate (eGFR) less than 30 mL/min, need for dialysis, and mortality. One hundred eighty-one patients were transplanted for HCV cirrhosis and 126 recipients had other causes of liver disease. Mean model for end-stage liver disease scores were 21.64 in the HCV group and 21.30 in the non-HCV group (P=0.58); 51% of patients in the HCV cohort had hepatocellular carcinoma compared with 27% in the non-HCV cohort (P<0.001). Mean pretransplant serum creatinine level was 0.89 mg/dL in both groups. At 3 years posttransplant, eGFR did not differ between the HCV and non-HCV cohorts (64.96 mL/min vs. 66.09 mL/min; P=0.71). A total of 14.4% of the patients with HCV achieved an eGFR less than 30 mL/min compared with 10.3% of the patients without HCV (P=0.13). There was no difference between the cohorts with respect to requirement for dialysis (P=0.73) or deaths (P=0.08), including those that were liver related (P=0.15). Patients with HCV cirrhosis and normal preliver transplant renal function do not have worse posttransplant renal outcomes compared with those with other causes of liver disease.

Pre-transplant Kidney Function Predicts Chronic Kidney Disease After Liver Transplant: Meta-Analysis of Observational Studies

Chronic kidney disease is a common problem in long-term survivors after liver transplantation. Several studies to clarify the risk factors for incidence of chronic kidney disease among liver transplant recipients, including preoperative kidney function, have yielded conflicting results. The aim of this study was to conduct a systematic review of the published medical literature on the impact of pre-transplant kidney function on the occurrence of chronic kidney disease after liver transplantation. Study-specific relative risks were weighted by the inverse of their variance to obtain fixed- and random-effects pooled estimates for incidence of chronic kidney disease across the published studies. The relative risk of chronic kidney disease after liver transplantation according to pre-transplant glomerular filtration rate was regarded as the most reliable outcome end-point. We identified seven studies (38,036 unique liver transplant recipients). A stratified analysis including only studies provided with glomerular filtration rate at transplant reported that the summary estimate of relative risk and 95% confidence intervals (CIs) for developing chronic renal failure among liver transplant recipients with diminished renal function at transplant was 2.12 (95% CI, 1.01; 4.46) (random-effects model). The p value for study heterogeneity was significant (p = 0.0001). Post-transplant chronic kidney disease shows impact on survival; the summary estimate for the adjusted relative risk of all-cause mortality with chronic kidney disease after liver transplant was 4.35 (95% confidence Intervals, 3.34; 5.66), p = 0.0001 (random-effects model). An increased risk of chronic kidney disease frequently exists among liver transplant recipients with reduced renal function at transplant. The occurrence of chronic kidney disease after liver transplantation has a major impact on mortality. Additional studies are needed to understand better the natural history of chronic kidney disease among liver transplant recipients.

Outcomes after liver transplantation: Chronic kidney disease

1. Chronic kidney disease is a common complication after liver transplantation and has a major impact on graft and patient survival. 2. Pretransplant renal dysfunction is the most important determinant of posttransplant chronic kidney disease; other factors include the presence of diabetes/hypertension, acute kidney injury pre-transplant and post-transplant, and the use of calcineurin inhibitor-based immunosuppression. 3. The most common cause of end-stage renal disease post-orthotopic liver transplantation is calcineurin inhibitor toxicity, and this emphasizes the need for calcineurin inhibitor minimization protocols post-transplant. 4. The presence of chronic kidney disease post-orthotopic liver transplantation not only is important with respect to the need for renal replacement therapy and kidney transplantation but also increases cardiovascular risk dramatically. 5. The Model for End-Stage Liver Disease score is partly driven by creatinine, and it is not uncommon to have an elevated creatinine level in those who have a high Model for End-Stage Liver Disease score and are close to having an organ allocated. Thus, evaluating patients with advanced liver disease and pretransplant acute kidney injury is challenging. It is important to identify pre-liver transplant patients at high risk for early evolution of chronic kidney disease post-transplant in order to appropriately select patients for combined liver/kidney transplantation.

Transplantation: Impact of pretransplant renal insufficiency

Pre-liver transplant renal dysfunction is associated with decreased survival following transplantation and is also a prognostic indicator of posttransplant chronic kidney disease. Selection of patients for combined liver/kidney transplantation versus orthotopic liver transplantation alone (OLTa) is often difficult given the lack of a reliable method to predict which patients will have ongoing severe renal dysfunction in the absence of concomitant kidney transplantation. We hypothesized that most patients with pretransplant renal dysfunction (serum creatinine > or = 1.5 mg/dL for at least 2 weeks prior to and at time of transplant) will not experience a rapid decline in estimated glomerular filtration rates (eGF) post-OLTa to the point of necessitating consideration for kidney transplantation, even in the setting of calcineurin inhibitor-based immunosuppression. We performed a single-center retrospective study of 60 OLTa patients with pretransplant renal dysfunction transplanted between 2000 and 2005. Kaplan-Meier analysis was performed of the time interval to develop eGFR < 20 mL/minute post-OLTa. At OLTa, the mean patient age was 59 years, and median serum creatinine was 1.8 mg/dL; 42% patients were hepatitis C-positive, 32% were diabetic, 38% had kidney dysfunction > 12 weeks, and 5% were receiving hemodialysis. After 36 months median follow-up post-OLTa, only 8 patients (13%) with significant renal dysfunction pre-OLTa achieved eGFR < 20 mL/minute. Patients with pretransplant kidney dysfunction > 12 weeks were at increased risk for eGFR < 20 mL/minute (hazard ratio = 5.3, P = 0.04), a risk that escalated after adjustment for age and serum creatinine at transplant (hazard ratio = 8.9, P = 0.01). Significant predictors of eGFR < 20 mL/minute post-OLTa in this patient cohort were the presence of diabetes and the serum creatinine level at transplant. In conclusion, few patients with preexisting renal dysfunction, especially if <12 weeks duration, experience a significant drop in eGFR post-OLTa.

Delayed Chronic Kidney Disease (CKD) after Hematopoietic Cell Transplantation (HCT).

Exposure to pre-transplant nephrotoxic agents, total body irradiation (TBI), and presence of chronic graft-versus-host disease (cGVHD) have been identified as risk factors for developing CKD after HCT. However, small sample size, short follow-up post-HCT, and varying definitions of CKD have precluded a precise estimation of the magnitude of risk and associated risk factors. The aim of the current study was to describe the incidence and risk factors associated with the development of delayed CKD in HCT survivors. Eligible subjects underwent HCT for hematological malignancies or severe aplastic anemia at City of Hope, survived at least one year post-transplant, and were free of CKD at one year post-HCT. Information on pre-transplant therapeutic exposures and post-transplant CKD was obtained via medical record abstraction. All CKD cases were defined according to the National Kidney Foundation's definition based on glomerular filtration rate (GFR) values. The endogenous filtration marker creatinine was used to estimate GFR values. CKD was defined as a sustained elevation of serum creatinine which infer a GFR of less than 60 mL/min/1.73 m2 for 3 months or longer. The equation used to calculate GFR was as follows: GFR = 186 x (Pcr) −1.154 x (age) − 0.203 (x 0.742 if female) (x 1.210 if African American). Totally, 1,546 eligible subjects were identified (median age at HCT of 34.4, median length of follow-up 6.2 years; autologous HCT in 718 patients [46%], related donor HCT in 726 patients [47%], and unrelated donor HCT in 102 patients [7%]; 59% of subjects (n=913) were male). A total of 65 patients were identified with CKD, resulting in a cumulative incidence of 3.6% [95% confidence interval (CI), 2.6% to 4.6%] at five years post–HCT and 4.8% at 10 years (autologous HCT: 2.9% at five years; matched sibling HCT: 4.1%; matched unrelated donor HCT: 10.5%, p<0.05). In allogeneic transplant recipients, older age at HCT (RR per increase of five years, 1.34; 95% CI, 1.30 to 1.38), prophylaxis/treatment of GvHD with cyclosporine and/or tacrolimus (RR, 4.32; 95% CI, 1.25 to 14.89), and a primary diagnosis of Multiple Myeloma (RR=5.38, 95% CI=1.79 to 16.15) were associated with increased risk. For autologous transplant recipients, older age at HCT was associated with increased risk (RR per increase of five years, 1.33; 95% CI, 1.29 to 1.38). Of note, use of TBI, and chemotherapeutic agents for conditioning, and a history of fungal infection were not associated with risk of delayed CKD development. This study describes the magnitude of risk of delayed chronic kidney disease in a large cohort of long-term survivors of autologous and allogeneic HCT, as well as identifies high risk groups in this population, thus setting the stage for appropriate long-term follow-up of the vulnerable sub–groups. [Display omitted] [Display omitted]