The liver recipient with acute renal dysfunction: A single institution evaluation of the simultaneous liver-kidney transplant candidate

Spontaneous peritoneal drainage following paracentesis in a hospitalized patient with resolution of type 1 hepatorenal syndrome

The hepatorenal syndrome develops in a small percentage of patients with advanced liver disease. The pathogenesis involves intravascular volume contraction secondary to pooling of blood in the splanchnic vessels, stimulation of the sympathetic nervous system and the renin-angiotensin-aldosterone pathway, and increased intra-abdominal pressure secondary to the formation of large volumes of ascitic fluid. The treatment options are limited, and liver transplant is the only definitive form of management. Here we suggest an alternative approach to treating hepatorenal syndrome based on the unexpected continuous peritoneal drainage in a 36-year-old man hospitalized with hepatic encephalopathy and hepatorenal syndrome. A total of 11.2 L ascitic fluid drained over 5 days from a paracentesis puncture site with marked improvement in renal function; the creatinine decreased from 3.3 mg/dL to 0.7 mg/dL and the BUN decreased from 42 mg/dL to 10 mg/dL. The discussion with this case report summarizes the pathogenesis, including the effect of intra-abdominal pressure, of the hepatorenal syndrome, outlines medical management, and makes a proposal for clinical study based on this case.

Evaluation of Longitudinal Exposure to Tacrolimus as a Risk Factor of Chronic Kidney Disease Occurrence Within the First-year Post-Liver Transplantation

BACKGROUND

Renal failure is predictive of mortality in the early postliver-transplantation period and calcineurin inhibitors toxicity is a main challenge. Our aim is to assess the impact of longitudinal tacrolimus exposure (TLE) and other variables on chronic kidney disease (CKD)-free 1-year-survival.

METHODS

Retrospective data of consecutive patients transplanted between 2011 and 2016 and treated with tacrolimus were collected. TLE and all relevant pre- and post-liver transplantation (LT) predictive factors of CKD were tested and included in a time-to-event model. CKD was defined by repeated estimated glomerular filtration rate (eGFR) values below 60 mL/min/1.73m2 at least for the last 3 months before M12 post-LT.

RESULTS

Data from 180 patients were analyzed. CKD-free survival was 74.5% and was not associated with TLE. Pre-LT acute kidney injury (AKI) and eGFR at 1-month post-LT (eGFRM1) <60 mL/min/1.73m2 were significant predictors of CKD. By distinguishing 2 situations within AKI (ie, with or without hepatorenal syndrome [HRS]), only HRS-AKI remained associated to CKD. HRS-AKI and eGFRM1 <60 mL/min/1.73m2 increased the risk of CKD (hazard ratio, 2.5; 95% confidence interval, 1.2-4.9; hazard ratio, 4.8; 95% confidence interval, 2.6-8.8, respectively).

CONCLUSIONS

In our study, TLE, unlike HRS-AKI and eGFRM1, was not predictive of CKD-free survival at 1-year post-LT. Our results once again question the reversibility of HRS-AKI.

Simultaneous liver kidney allocation policy and the Safety Net: an early examination of utilization and outcomes in the United States

Rates of simultaneous liver kidney (SLK) transplantation in the United States have progressively risen. On 8/10/17, the Organ Procurement and Transplantation Network implemented a policy defining criteria for SLK, with a "Safety Net" to prioritize kidney allocation to liver recipients with ongoing renal failure. We performed a retrospective review of the United Network for Organ Sharing (UNOS) database to evaluate policy impact on SLK, kidney after liver (KAL) and kidney transplant alone (KTA). Rates and outcomes of SLK and KAL transplants were compared, as was utilization of high-quality kidney allografts with Kidney Donor Profile Indices (KDPI) <35%. Here, SLK transplants comprised 9.0% and 4.5% of total postpolicy liver and kidney transplants compared to 10.2% and 5.5% prior. Policy enactment did not affect 1-year graft or patient survival for SLK and KAL populations. Less postpolicy SLK transplants utilized high-quality kidney allografts; in all transplant settings, outcomes using high-quality grafts remained stable. These findings suggest that policy implementation has reduced kidney allograft use in SLK transplantation, although both SLK and KAL rates have recently increased. Despite decreased high-quality kidney allograft use, SLK and KAL outcomes have remained stable. Additional studies and long-term follow-up will ensure optimal organ access and sharing.

Early Acute Kidney Injury Associated with Liver Transplantation: A Retrospective Case-Control Study

Background

A retrospective case-control study was carried out to assess the occurrence of acute kidney injury (AKI) in liver transplantation (LT) recipients and its related risk factors.

Material/Methods

The study enrolled 131 patients undergoing LT from December 2017 to June 2019 at Beijing Tsinghua Chang Gung Hospital, China. AKI and its classification were defined according to KDIGO guidelines. We collected patients’ demographic characteristics and perioperative parameters, and identified independent risk factors of AKI by multivariate logistic regression analysis.

Results

We included 122 patients in analysis. AKI occurred in 52 (42.6%) patients (22.1% stage I, 8.2% stage II, and 12.3% stage III). AKI was notably associated with 12 factors: sex, body mass index (BMI), hepatic etiology, MELD score, ascites, prothrombin time (PT), international normalized ratio of prothrombin time (INR), preoperative total bilirubin (TBIL), operative time, total fluid intake, fresh frozen plasma (FFP), and estimated blood loss (EBL) (P<0.05). The factors independently associated with AKI were BMI (adjusted odds ratio: 0.605, 95% confidence interval: 0.425–0.859; P=0.005) and intraoperative FFP infusion (adjusted odds ratio: 0.998, 95% confidence interval: 0.995–1.000; P=0.047). Compared with the non-AKI group, the AKI group showed higher likelihood of renal replacement therapy (RRT), and longer ICU and hospital stays, higher in-hospital mortality, and higher hospitalization costs (P<0.05).

Conclusions

There is a high risk of AKI in patients undergoing LT. BMI and intraoperative FFP infusion are factors independently correlated with AKI. AKI can result in extended hospital stays and higher hospitalization expenses.