Both acute and chronic renal insufficiency are highly prevalent in liver transplant recipients. The etiology is multifactorial, with administration of nephrotoxic drugs playing a major role. Calcineurin inhibitors (CNI) (cyclosporin and tacrolimus) are the mainstay of immunosuppressive therapy in liver transplantation and produce acute and chronic nephrotoxicity. There are three main strategies to prevent renal injury: a) reduction of CNI to minimal levels accompanied by the use of an adjuvant drug such as azathioprine, mycophenolate mofetil or mammalian target of rapamycin (mTOR) inhibitors; b) complete withdrawal of CNI, using non-nephrotoxic drugs in their place; and c) use of protocols without CNI from the outset. The present article reviews these three strategies as well as their influence on renal function and on the results of liver transplantation.
