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Preoperative acute renal failure, renal replacement therapy increased liver transplant mortality risk

Liver transplant recipients with preoperative acute renal failure who received renal replacement therapy were at greater risk for death than patients with preoperative acute-on-chronic renal failure in a recent study.

In a post-hoc analysis, researchers evaluated mortality rates in a cohort of 135 patients aged older than 16 years who underwent liver transplantation at a medical facility between January 2003 and December 2008. Patients were divided into four groups according to preoperative creatinine clearance and whether renal replacement therapy (RRT) was necessary post-transplantation:

• Group 1: Acute renal failure, normal creatinine clearance (above 60 mL/min as measured by the Cockcroft formula) with RRT (n=15)
• Group 2: Normal creatinine clearance without RRT (n=85)
• Group 3: Acute-on-chronic renal failure, low creatinine clearance (60 mL/min or lower) with RRT (n=10)
• Group 4: Low creatinine clearance without RRT (n=25)

Incidence of hospital (P=.002) and ICU mortality (P=.008) differed between the groups, as did cumulative survival rates (P<.0001). Patients in group 1 had the highest mortality rates, including 46.7% overall, 26.6% hospital, 20% ICU and 50% cumulative mortality at 1 year. These patients experienced sepsis (P=.0001) and respiratory failure requiring reintubation (P=.009), were readmitted to the ICU (P=.006) and required reoperation (P=.0014) more frequently, and also experienced significantly longer ICU stays (P=.0003) compared with group 2.Investigators calculated an HR for mortality of 9.6 (3.2-28.6) for group 1, and a nonsignificant HR of 5.6 (0.5-62.5) for group 3.

“Our data demonstrate that … acute renal failure with RRT is a strong predictor of death and, in turn, determines the outcome of liver transplanted patients,” the researchers wrote. “In contrast, interestingly … acute-on-chronic renal failure seems to be of minor importance in terms of mortality and outcome. The fact that, in two-thirds of the patients with pre-existing renal function no RRT is necessary, gives evidence that cautious operative strategy and prudent perioperative management can avoid postoperative RRT.”