Accurate assessment of hepatic fibrosis and portal hypertension (PH) is essential in patients with end-stage renal disease (ESRD) who are suspected to have advanced hepatic fibrosis, as this may influence the choice between isolated renal transplantation and combined liver–kidney (hepato-renal) transplantation. Endoscopic ultrasound (EUS)-guided portal pressure gradient (PPG) measurement (EUS-PPG) provides a minimally invasive alternative to the hepatic venous pressure gradient (HVPG) for evaluating PH, and can be combined with multimodality endoscopic assessment in a single session. However, the procedure can be technically challenging in patients with ESRD due to increased bleeding risk and altered anatomy, such as in those with polycystic liver disease. The aim of our study was to evaluate the safety, feasibility, and impact of EUS-PPG on clinical decision-making in this patient group. 

A prospective therapeutic EUS registry was reviewed retrospectively, focusing on patients with ESRD who were suspended from the renal transplant list due to suspected underlying liver disease. Patients with ESRD undergoing EUS-PPG measurement with or without concurrent endoscopic variceal screening, elastography, and liver biopsy between August 2023 and August 2025 were included. Patient demographic data, clinical characteristics, Endoscopic findings, PPG values, histopathology findings, and procedure-related complications were recorded and analysed. Clinically significant portal hypertension (CSPH) was defined as a PPG ≥ 10 mmHg. The primary outcome was the impact of EUS-PPG on transplant decision-making, while secondary outcomes included the safety and feasibility of the procedure.   

A total of 7 patients with ESRD who had been suspended from the renal transplant list were included (4 female, 3 male; mean age 52 years). All EUS-PPG procedures were technically successful, with PPG values ranging from 3–6 mmHg. 5 patients underwent EUS-guided liver biopsy, and all specimens were adequate for histological analysis. Each biopsy met key performance indicators i.e. total specimen length ≥20 mm, and presence of ≥11 complete portal tracts. One patient experienced minor post-biopsy bleeding requiring a short hospital stay but no intervention. None of the patients demonstrated clinically significant portal hypertension. Based on these findings, all patients were recommended for reinstatement on the isolated renal transplant list. No adverse events were observed during follow-up.   

EUS-PPG measurement, with or without concurrent liver biopsy, is a feasible, safe, and clinically valuable tool for assessing hepatic fibrosis and portal hypertension in renal transplant candidates. It provides critical hemodynamic and histologic information in a single session, thereby informing transplant eligibility decisions and potentially avoiding unnecessary combined liver–kidney transplantation.