Date Published: June 2, 2017
Publisher: Public Library of Science
Author(s): Maria Claudia Cruz Andreoli, Nádia Karina Guimarães de Souza, Adriano Luiz Ammirati, Thais Nemoto Matsui, Fabiana Dias Carneiro, Ana Claudia Mallet de Souza Ramos, Ilson Jorge Iizuca, Maria Paula Vilela Coelho, Rogério Carballo Afonso, Ben-Hur Ferraz-Neto, Marcio Dias de Almeida, Marcelino Durão, Marcelo Costa Batista, Julio Cesar Monte, Virgílio Gonçalves Pereira, Oscar Pavão dos Santos, Bento Cardoso dos Santos, Stanislaw Stepkowski.
Renal dysfunction frequently occurs during the periods preceding and following orthotopic liver transplantation (OLT), and in many cases, renal replacement therapy (RRT) is required. Information regarding the duration of RRT and the rate of kidney function recovery after OLT is crucial for transplant program management. We evaluated a sample of 155 stable patients undergoing post-intensive care hemodialysis (HD) from a patient population of 908 adults who underwent OLT. We investigated the average time to renal function recovery (duration of RRT required) and determined the risk factors for remaining on dialysis > 90 days after OLT. Log-rank tests were used for univariate analysis, and Cox proportional hazards models were used to identify factors associated with the risk of remaining on HD. The results of our analysis showed that of the 155 patients, 28% had pre-OLT diabetes mellitus, 21% had pre-OLT hypertension, and 40% had viral hepatitis. Among the patients, the median MELD (Model for End-Stage Liver Disease) score was 27 (interquartile range [IQR] 22-35). When they were listed for liver transplantation, 32% of the patients had serum creatinine (Scr) levels > 1.5 mg/dL or were on HD, and 50% had serum creatinine (Scr) levels > 1.5 mg/dL or were on HD at the time of OLT. Of the transplanted patients, 25% underwent pre-OLT intermittent HD, and 14% and 41% underwent continuous renal replacement therapy (CRRT) pre-OLT and post-OLT, respectively. At 90 days post-OLT, 118 (76%) patients had been taken off dialysis, and 16 (10%) patients had died while undergoing HD. The median recovery time of these post-OLT patients was 33 (IQR 27–39) days. In the multivariate analysis, fulminant hepatic failure as the cause of liver disease (p<0.001), the absence of pre-OLT hypertension (p = 0.016), a lower intraoperative fresh-frozen plasma (FFP) transfusion volume (p = 0.019) and not undergoing pre-OLT intermittent HD (p = 0.032) were associated with performing RRT for less than 90 days. Therefore, a high proportion of OLT patients showed improved renal function after OLT, and those who were diagnosed with fulminant hepatic failure, had no pre-OLT hypertension, received a lower transfused volume of intraoperative FFP and did not undergo pre-OLT intermittent HD had a higher probability of recovery.
In the MELD (Model for End-Stage Liver Disease) score era of organ allocation, which considers serum levels of creatinine and bilirubin and the international normalized ratio of the prothrombin time, patients are prioritized based on measures of preoperative renal dysfunction. Between 5% and 35% of liver transplant patients require perioperative dialysis for renal replacement therapy (RRT) . Information regarding a patient’s RRT duration requirements and probability of kidney function recovery is crucial for transplant program management.
Renal failure in cirrhotic patients is a challenging complication with a significant impact on mortality both before and after OLT [6, 7]. As the Scr level is a component of the MELD score, the number of patients with renal dysfunction who undergo OLT and the proportion of OLTs performed in combination with kidney transplants have increased [8, 9]. Patients with normal or mild impairment of renal function pre-OLT whose status deteriorates during the perioperative period may need RRT. A key point of this scenario is that it is important to determine the nature of renal dysfunction and anticipate whether kidney function could recover after post-OLT liver function recovery. In the present study, we evaluated 155 stable post-OLT patients who did not have chronic irreversible renal disease diagnosed preoperatively and required RRT (HD) post-intensive care hospitalization. Our objective was to describe the average time to renal recovery and identity the factors associated with remaining on RRT > 90 days after OLT among patients undergoing RRT. We observed that at 90 days post-OLT, 21 patients (14%) were undergoing RRT, and after 1 year, only 5 (3%) remained on dialysis. The proportion of patients in our study who recovered renal function was higher than that observed in a previous, larger study .