This study utilizes a substantial cohort of 952 liver transplant patients with a median follow-up duration of 97.3 months [8]. The authors rigorously assess the long-term effects of tacrolimus levels and IPV on the progression of CKD and ESRD following LT, utilizing kidney function trends, risk factor analysis, and sophisticated statistical methodologies, such as time-dependent competing risk models, to enhance the robustness of the results. The current study offers practical recommendations for transplant-related physicians and transplant surgeons, including keeping tacrolimus levels below 4.0 ng/mL beyond the first year post-transplantation and treating IPV to mitigate the chances of CKD and ESRD. This research also underscores the effects of tenofovir disoproxil fumarate in patients infected with hepatitis B virus (HBV), providing customized management approaches for this high-risk population.

The development of CKD post-transplantation is affected by pre-transplant renal function; however, multiple factors interact in a complex manner [1]. This study identifies disparities in baseline features across the comparison groups, including an elevated incidence of CKD (59.5%) and ESRD (10%) in the acute kidney injury group relative to the normal glomerular filtration rate group. The difficulties of attributing the onset of CKD and ESRD post-transplantation to tacrolimus trough levels and IPV are evident, considering the definitive state of kidney function before and after transplantation. Elevated IPV may arise from multiple sources. IPV is influenced by poor medication adherence and the presence or lack of cytochrome 3A5 expression [5]. In addition, various complications including biliary complications, infections, HBV recurrence, hepatocellular carcinoma recurrence, and de novo malignancy necessitate ongoing adjustments in tacrolimus dosage, which can perpetuate liver graft and renal injury, potentially culminating in CKD and ESRD [7,9,10]. In the present study, patients did not undergo tacrolimus monotherapy exclusively. A multitude of patients received combination therapy using mammalian target of rapamycin inhibitors or mycophenolate mofetil. It is necessary to examine the impact of this combination of medications on renal function. Additionally, research on the impact of tacrolimus IPV should be carried out using homogeneous data devoid of exceptional events to yield unequivocal evidence.

Lee et al.’s study significantly enhances our understanding of CKD and ESRD hazards post-transplantation by identifying optimal tacrolimus dosages and emphasizing the significance of IPV [8]. These findings provide insight that will inform clinical guidelines; however, further research is necessary to mitigate the limitations and confirm the results in various contexts.