Response to treatment for AKI improved 90-day survival in patients waitlisted for LT

Key takeaways:

• Patients waitlisted for LT who responded to treatment for acute kidney injury had higher 90-day overall and transplant-free survival.
• Treatment responders also had shorter hospital and ICU lengths of stay.

BOSTON — Response to treatment for acute kidney injury correlated with improved 90-day survival and shorter lengths of hospital stay among patients with cirrhosis waitlisted for liver transplant, according to data at The Liver Meeting.

“[Acute kidney injury] in cirrhosis occurs commonly in hospitalized patients with cirrhosis and leads to worse outcomes,” Xing Li, MD, MBA, a third-year gastroenterology fellow at Massachusetts General Hospital, told Healio. “Renal recovery from AKI has been shown to favorably impact prognosis in patients with cirrhosis. However, specifically for patients on the waiting list for LT, how AKI response affects survival and, importantly, LT rate and timing has not been thoroughly investigated.”

Li continued, “This question becomes even more relevant to clinical practice with the recent approval of the vasoconstrictor medication terlipressin for the treatment of HRS-AKI in the U.S.”

In a secondary analysis of a patient database built by the HRS-HARMONY collaborative research consortium, Li and colleagues assessed 2,057 adults with cirrhosis who were hospitalized with acute kidney injury (AKI) in 2019 at 11 U.S. transplant centers, of whom 317 were waitlisted for LT.

Researchers compared 90-day overall and transplant-free survival rates, LT rate and timing, and resource utilization among those who responded to medical management, defined as a decrease in serum creatinine to within 0.3 mg/dL of baseline or regression of AKI stage, and those who did not.

According to results, 53.6% of patients responded to medical management while 46.4% did not. After adjusting for age, sex, race etiology of cirrhosis, study site and MELD-Na score, researchers also reported that those who responded to treatment had improved 90-day overall survival (89.4% vs. 76.2%; adjusted HR = 0.34; 95% CI, 0.18-0.65) and transplant-free survival (63.5% vs. 25.5%; aHR = 0.35; 95% CI, 0.25-0.5).

Responders also had a lower rate of LT (45.9% vs. 61.2%; aHR = 0.55; 95% CI, 0.37-0.84), with the majority (79%) of LT occurring after discharge at a median of 103 days. Among non-responders, 62% required LT during hospitalization, while the remainder underwent LT after a median 58 days after discharge.

“We observed that patients whose AKI improved or recovered during hospitalization did significantly better in terms of overall survival compared to patients whose AKI did not,” Li said. “This really highlights the importance of promptly recognizing and treating AKI in cirrhosis regardless of etiology, with appropriate medical therapy.”

Results also showed that responders had shorter ICU and hospital lengths of stay, by a median of 6 and 10 days, respectively, and fewer patients required ICU, intubation, renal replacement therapy and pressor use.

“We did observe lower rate of transplant in responders compared to non-responders and a longer time to transplant,” Li told Healio. “How we interpreted this finding was that there was a subset of patients whose AKI resolved or improved during hospitalization and who did not need a transplant in the short-term; however, there were also patients — 45% of responders — who still required LT eventually after that index AKI event.”

Li continued: “For these patients, transplants were more likely to occur after discharge, perhaps in a more controlled setting, as opposed to during the index admission for non-responders. This suggests that patients should be closely monitored after discharge, even in those with AKI recovery for potential need for transplant.”