Predicting renal recovery after liver transplant with severe pretransplant subacute kidney injury: The impact of warm ischemia time.
Identifying which liver transplantation (LT) candidates with severe kidney injury will have a full recovery of renal function after liver transplantation alone (LTA) is difficult. Avoiding unnecessary simultaneous liver-kidney transplantation (SLKT) can optimize the use of scarce kidney grafts. Incorrect predictions of spontaneous renal recovery after LTA can lead to increased morbidity and mortality. We retrospectively analyzed all LTA patients at our institution from February 2002 to February 2013 (n = 583) and identified a cohort with severe subacute renal injury (n = 40; creatinine <2 mg/dL in the 14-89 days prior to LTA and not on renal replacement therapy [RRT] yet, ≥2 mg/dL within 14 days of LTA and/or on RRT). Of 40 LTA recipients, 26 (65%) had renal recovery and 14 (35%) did not. The median (interquartile range) warm ischemia time (WIT) in recipients with and without renal recovery after LTA was 31 minutes (24-46 minutes) and 39 minutes (34-49 minutes; P = 0.02), respectively. Adjusting for the severity of the subacute kidney injury with either Acute Kidney Injury Network or Risk, Injury, Failure, Loss, and End-Stage Kidney Disease criteria, increasing WIT was associated with lack of renal recovery (serum creatinine <2 mg/dL after LTA, not on RRT), with an odds ratio (OR) of 1.08 (1.01-1.16; P = 0.03) and 1.09 (1.01-1.17; P = 0.02), respectively. For each minute of increased WIT, there was an 8%-9% increase in the risk of lack of renal recovery after LTA. In a separate cohort of 98 LTA recipients with subacute kidney injury, we confirmed the association of WIT and lack of renal recovery (OR, 1.04; P = 0.04). In LT candidates with severe subacute renal injury, operative measures to minimize WIT may improve renal recovery potentially avoiding RRT and the need for subsequent kidney transplant. Liver Transplantation 22 1085-1091 2016 AASLD.
Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO.
Heather L
HL
Laskey
Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO.
Nathan
N
Schomaker
Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO.
Kenneth W
KW
Hung
Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX.
Sumeet K
SK
Asrani
Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX.
Linda
L
Jennings
Department of Surgery, University of Colorado Denver, Denver, CO.
Trevor L
TL
Nydam
Department of Pediatrics and Biostatistics and Informatics, University of Colorado Denver, Denver, CO.
Jane
J
Gralla
Division of Nephrology, University of Colorado Denver, Denver, CO.
Alex
A
Wiseman
Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO.
Hugo R
HR
Rosen
Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO.
Scott W
SW
Biggins
D058186:Acute Kidney Injury / Q000097:blood / Q000175:diagnosis* / Q000401:mortality; D000328:Adult; D003404:Creatinine / Q000097:blood; D058625:End Stage Liver Disease / Q000401:mortality / Q000601:surgery*; D005260:Female; D006801:Humans; D007668:Kidney / Q000503:physiopathology*; D007677:Kidney Function Tests; D016031:Liver Transplantation / Q000009:adverse effects* / Q000379:methods; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D020127:Recovery of Function; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome; D052096:Warm Ischemia / Q000009:adverse effects*
D003404:Creatinine