Pretransplant predictors of recovery of renal function after liver transplantation

Abstract

The Model for End-Stage Liver Disease system has given priority on the liver transplant waiting list to candidates with renal failure. This study determined the predictors of spontaneous recovery of renal function after transplantation in 1041 liver transplant recipients on renal replacement therapy (RRT) at the time of transplant (from February 2002 to January 2007). Data from these patients were obtained from the US Organ Procurement and Transplantation Network and US Renal Data System databases. Univariate and multivariate survival models were constructed along with multivariate logistic regression models to find independent predictors of spontaneous renal recovery. Seven hundred seven recipients (67.9%) had spontaneous recovery of renal function after liver transplantation. Those recovering spontaneously had a significantly shorter course of RRT in the pretransplant time period (15.6 versus 36.6 days, P < 0.001). Recovery of renal function was observed in 70.8% and 11.5% of recipients on RRT for less than 30 days and more than 90 days, respectively. Other statistically significant pretransplant variables independently associated with recovery of renal function included recipient age, recipient pretransplant diabetes, and donor age. In conclusion, the duration of pretransplant RRT is highly predictive of spontaneous renal recovery post-transplant. Liver transplant candidates requiring less than 30 days of pretransplant RRT are likely to spontaneously recover renal function after liver transplantation, whereas those on RRT for more than 90 days are not. In the era of Model for End-Stage Liver Disease (MELD)-based liver allocation, there has been a preference for organ allocation to those patients with renal dysfunction, with the result that more than 30% of patients awaiting liver transplantation have decreased renal function, including a substantial number that require renal replacement therapy (RRT). 1,2 This has coincided with a rise in combined liver-kidney transplantation (CLKT) in the past 7 years. Impaired renal function at the time of transplantation has been shown to have a detrimental impact on morbidity and mortality after liver transplantation. 2,3 Despite imprecise methods for measuring renal dysfunction, 4 it is clear that the pretransplant degree of renal insufficiency has a major impact on post-transplant survival. 5 Specifically, the length of pretransplant renal dysfunction predicts post-transplant renal insufficiency. Campbell et al. 6 demonstrated that the duration of pretransplant Abbreviations: CI, confidence interval; CLKT, combined liver-kidney transplantation; INR, international normalized ratio; MELD, Model for End-Stage Liver Disease; N/A, not available; OR, odds ratio; RRT, renal replacement therapy; UNOS,

Short-Term Pretransplant Renal Replacement Therapy and Renal Nonrecovery after Liver Transplantation Alone

“…One study showed the renal nonrecovery to be as high as 32% among LT recipients who were on pre-LTRRT and received LT alone (9). However, this study did not distinguish between the candidates receiving acute and chronic RRT before LT. Our primary and secondary objectives were to assess the reversibility of AKI among those who were on acute RRT for #90 days before LT and to determine the minimum threshold of the duration of pre-LT RRT above which the risk of renal nonrecovery was substantially increased.…”

“…Although candidates with AKI including HRS may recover renal function after LT (7)(8)(9), the rate and timing of renal recovery have not been very well elucidated. One study showed the renal nonrecovery to be as high as 32% among LT recipients who were on pre-LTRRT and received LT alone (9).…”

Inferior long-term outcomes of liver-kidney transplantation using donation after cardiac death donors: Single-center and organ procurement and transplantation network analyses

“…In these patients, early recovery of the renal graft is crucial because of the effect of posttransplant renal failure on overall transplant outcomes. [20][21][22] DGF was twice as common in the DCD- 23 In addition to the efforts by the transplant community to increase organ availability, the issue of allocating organs to maximize the benefit to individual patients should be considered. This study raises a serious dilemma about the best way to use DCD organs.…”

To whom goes the kidney?

“…2,[4][5][6] In the other corner are data suggesting that upward of 80% of liver transplant recipients on renal replacement therapy (RRT) for fewer than 30 days go on to recover renal function after transplantation, and this indicates that at least some kidneys transplanted as part of SLK are unnecessary. 7 To whom then goes the kidney, the liver transplant candidate with renal impairment or the kidney transplant candidate?…”

“…2,[4][5][6] In the other corner are data suggesting that upward of 80% of liver transplant recipients on renal replacement therapy (RRT) for fewer than 30 days go on to recover renal function after transplantation, and this indicates that at least some kidneys transplanted as part of SLK are unnecessary. 7 To whom then goes the kidney, the liver transplant candidate with renal impairment or the kidney transplant candidate?There is little debate about the necessity for SLK among end-stage renal disease patients with decompensated cirrhosis because these patients have no hope of recovering renal function and would not survive kidney transplantation alone; this establishes a clear role for SLK. 8 Therefore, how we frame the discussion about SLK is critical.…”