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. 2024 Oct;69(10):3710-3720.
doi: 10.1007/s10620-024-08623-2. Epub 2024 Aug 31.

Prognosis of Transplant-Ineligible Patients with Cirrhosis and Acute Kidney Injury Who Initiate Renal Replacement Therapy

Paige McLean Diaz  1 , Danielle L Saly  2 , Nora Horick  3 , Romela Petrosyan  4 , Zachary Gitto  5 , Teresa Indriolo  6 , Lucinda Li  6 , Olivia Kahn-Boesel  7 , John Donlan  7 , Blair Robinson  8 , Lindsay Dow  8 , Annie Liu  2 , Areej El-Jawahri  9 , Xavier Vela Parada  10 , Sara Combs  11 , Joao Teixeira  12 , Raymond Chung  6 , Andrew S Allegretti  2 , Nneka N Ufere  13
Affiliations

Prognosis of Transplant-Ineligible Patients with Cirrhosis and Acute Kidney Injury Who Initiate Renal Replacement Therapy

Paige McLean Diaz et al. Dig Dis Sci. 2024 Oct.

Abstract

Background: Data to guide dialysis decision-making for transplant-ineligible patients with cirrhosis are lacking.

Aims: We aimed to describe the processes, predictors, and outcomes of renal replacement therapy (RRT) initiation for transplant-ineligible patients with cirrhosis at a single liver transplantation center.

Methods: We conducted a mixed-methods study of a retrospective cohort of 372 transplant-ineligible inpatients with cirrhosis with acute kidney injury (AKI) due to hepatorenal syndrome (HRS-AKI) or acute tubular necrosis (ATN) between 2008 and 2015. We performed survival analyses to evaluate 6-month survival and renal recovery and examined end-of-life care outcomes. We used a consensus-driven medical record review to characterize processes leading to RRT initiation.

Results: We identified 266 (71.5%) patients who received RRT and 106 (28.5%) who did not receive RRT (non-RRT). Median survival was 12.5 days (RRT) vs. 2.0 days (non-RRT) (HR 0.36, 95%CI 0.28-0.46); 6-month survival was 15% (RRT) vs. 0% (non-RRT). RRT patients were more likely to die in the intensive care unit (88% vs. 32%, p < 0.001). HRS-AKI patients were more likely to be RRT dependent at 6 months than ATN patients (86% vs. 27%, p = 0.007). The most common reasons for RRT initiation were unclear etiology of AKI on presentation (32%) and belief of likely reversibility of ATN (82%).

Conclusion: Most transplant-ineligible patients who were initiated on RRT experienced very short-term mortality and received intensive end-of-life care. However, approximately 1 in 6 were alive at 6 months. Our findings underscore the critical need for structured clinical processes to support high-quality serious illness communication and RRT decision-making for this population.

Keywords: Acute on chronic liver failure; Dialysis; End-stage liver disease; Palliative care; Palliative hepatology.

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Conflict of interest statement

Conflict of interest The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Patient flow diagram. ATN acute tuberculosis, HRS-AKI hepatorenal syndrome, RRT renal replacement therapy
Fig. 2
Fig. 2
Kaplan–Meier curve for transport-ineligible patients with severe acute kidney injury after 6 months, based on the receipt of renal replacement therapy (RRT)
Fig. 3
Fig. 3
Summary of unadjusted outcomes at 6 months among 266 transplant-ineligible patients with cirrhosis initiated on RRT for severe AKI. ATN acute tubular necrosis, HRS-AKI hepatorenal syndrome, RRT renal replacement therapy
See this image and copyright information in PMC

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