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Liver disease is commonly associated with renal dysfunction (see Chapter 77 – Simultaneous Liver-Kidney Transplantation). Combined liver–kidney transplantation can treat patients with cirrhosis and advanced chronic kidney disease.

A renal biopsy is performed in selected patients for accurate diagnosis of the etiology of the renal dysfunction and to assess its potential for reversibility after liver transplantation.

A transjugular renal biopsy can replace the conventional percutaneous biopsy in cirrhotic patients with high risk of bleeding due to coagulopathy and thrombocytopenia.


Renal biopsies in this setting show a variety of lesions ranging from minimal abnormalities to extensive scarring (end-stage renal disease). The most common glomerular processes relate to the liver disease itself (i.e., secondary IgA nephropathy, hepatitis C–related glomerulonephritis). However, a variety of other glomerular, tubular, and/or vascular processes are also identified.

  • Nonspecific pathologic changes:

    • Mesangioproliferative glomerulonephritis (Fig. 101-1)

    • Mild ultrastructural abnormalities (Fig. 101-2)

    • Hypertensive nephropathy (global and segmental glomerulosclerosis, tubulointerstitial atrophy/fibrosis, vascular sclerosis) (Fig. 101-3)

  • Glomerular diseases:

  • Diabetic nephropathy (Fig. 101-7)

  • Tubular disease:

For additional information see Refs. 1–4.

FIGURE 101-1

(A) Mesangioproliferative glomerulonephritis of unclear etiology in a patient with cirrhosis due to Wilson disease. A renal biopsy was performed for mild proteinuria and hematuria while the patient awaited liver transplantation. Periodic acid–Schiff (PAS) stain demonstrates expansion of the mesangial areas due to an increase in mesangial cells and matrix (arrows). The capillary lumina and capillary basement membranes are normal. Immunofluorescence studies and electron microscopy did not demonstrate immune deposits. (B) Mesangioproliferative glomerulonephritis in a patient with cirrhosis due to chronic hepatitis C. The PAS stain highlights all mesangial areas, which show accumulation of amorphous material (mesangial matrix) and nuclear profiles (increase in cellularity). Immunofluorescence studies and electron microscopy did not demonstrate significant immune deposits. (C) Electron microscopy image corresponding to the biopsy presented in Part A. The mesangial area (asterisk) is bulky due to an increase in the extracellular (mesangial) matrix and cellular population. The remaining components of the glomerulus are normal (basement membranes, foot processes of podocytes, arrows).

FIGURE 101-2

Electron microscopic images in patients with minor glomerular abnormalities while awaiting liver transplantation. (A) Mesangial electron dense (immune-type) deposits (arrow) in a patient with alcoholic cirrhosis. The deposits stained with IgA on immunofluorescence. Secondary IgA nephropathy is common in patients with cirrhosis. (B) Effacement of the foot processes of podocytes (arrows) in a patient with history of NSAID abuse. (C) Wrinkling (folding) of the glomerular basement membranes ...

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