Liver transplantation in recipients receiving renal replacement therapy: outcomes analysis and the role of intraoperative hemodialysis.
The Model for End-Stage Liver Disease (MELD) system has dramatically increased the number of recipients requiring pretransplant renal replacement therapy (RRT) prior to liver transplantation (LT). Factors affecting post-LT outcomes and the need for intraoperative RRT (IORRT) were analyzed in 500 consecutive recipients receiving pretransplant RRT, including comparisons among recipients not receiving IORRT (No-IORRT, n = 401), receiving planned IORRT (Pl-IORRT, n = 70), and receiving emergent, unplanned RRT after LT initiation (Em-IORRT, n = 29). Despite a median MELD of 39, overall 30-day, 1-, 3- and 5-year survivals were 93%, 75%, 68% and 65%, respectively. Em-IORRT recipients had significantly more intraoperative complications (arrhythmias, postreperfusion syndrome, coagulopathy) compared with both No-IORRT and Pl-IORRT and greater 30-day graft loss (28% vs. 10%, p = 0.004) and need for retransplantation (24% vs. 10%, p = 0.099) compared with No-IORRT. A risk score based on multivariate predictors of IORRT accurately identified recipients with chronic (sensitivity 84%, specificity 72%, concordance-statistic [c-statistic] 0.829) and acute (sensitivity 93%, specificity 61%, c-statistic 0.776) liver failure requiring IORRT. In this largest experience of LT in recipients receiving RRT, we report excellent survival and propose a practical model that accurately identifies recipients who may benefit from IORRT. For this select group, timely initiation of IORRT reduces intraoperative complications and improves posttransplant outcomes.
Department of Surgery, Dumont-UCLA Transplant and Liver Cancer Centers, Pfleger Liver Institute, University of California, Los Angeles, CA.
V G
VG
Agopian
A
A
Dhillon
J
J
Baber
F M
FM
Kaldas
A
A
Zarrinpar
D G
DG
Farmer
H
H
Petrowsky
V
V
Xia
H
H
Honda
J
J
Gornbein
J R
JR
Hiatt
R W
RW
Busuttil
D000328:Adult; D058625:End Stage Liver Disease / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006085:Graft Survival; D006801:Humans; D007430:Intraoperative Care; D007674:Kidney Diseases / Q000628:therapy*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011379:Prognosis; D011446:Prospective Studies; D020127:Recovery of Function; D006435:Renal Dialysis; D012189:Retrospective Studies; D015996:Survival Rate
Hemodialysis; liver transplantation; outcomes; pretransplant renal failure; renal disease in liver transplantation