The progression of hepatorenal syndrome-acute kidney injury in acute alcohol-associated hepatitis: renal outcomes after liver transplant

Alessandro Colletta; Katherine M Cooper; Deepika Devuni

doi:10.1177/17562848231188813

The progression of hepatorenal syndrome-acute kidney injury in acute alcohol-associated hepatitis: renal outcomes after liver transplant

Therap Adv Gastroenterol. 2023 Jul 31:16:17562848231188813. doi: 10.1177/17562848231188813. eCollection 2023.

Authors

Alessandro Colletta¹, Katherine M Cooper², Deepika Devuni³

Affiliations

¹ UMass Chan Medical School, 55 Lake Ave North, Worcester, MA 01655, USA.
² UMass Chan Medical School, Worcester, MA, USA.
³ UMass Chan Medical School, Division of Gastroenterology, Worcester, MA, USA.

Abstract

Background: Hepatorenal syndrome-acute kidney injury (HRS-AKI) is a complication of advanced liver disease in patients with ascites and circulatory dysfunction. Little data remain on the relationship between HRS-AKI outcomes and different etiologies of liver disease post-liver transplant (LT).

Objectives: The primary aim was to evaluate the effect of HRS-AKI on renal outcomes in patients with acute alcohol-associated hepatitis (AAH) compared to chronic liver disease (CLD) after LT. The secondary aim was to evaluate the impact of acuity and chronicity of alcohol-associated liver disease in patients with HRS-AKI post-LT renal outcomes.

Design: A retrospective observational study of patients undergoing urgent inpatient liver transplant evaluation (LTE) for cirrhosis and AAH at single academic LT center between October 2017 and July 2021 was conducted.

Methods: Patients with HRS-AKI were selected based on indication for LTE: acute AAH_HRS or CLD_HRS. CLD_HRS was categorized by disease etiology: cirrhosis due to alcohol (A-CLD_HRS) versus cirrhosis from other causes (O-CLD_HRS). CLD patients without HRS-AKI were labeled CLD_{no HRS}.

Results: A total of 210 subjects underwent LTE; 25% were evaluated for AAH and 75% were evaluated for CLD. Hepatorenal syndrome was more common in subjects evaluated for AAH (37/47) than CLD (104/163) (78.7 versus 63.8%, p = 0.04). For the primary outcome, AAH_HRS subjects required ⩾30 days post-LT renal replacement therapy (RRT) more often than subjects with CLD_HRS (p = 0.02) and CLD_{no HRS} (p < 0.01). There was no significant difference in other forms of long-term renal outcomes including kidney transplant referral and kidney transplant among cohorts. In subgroup analysis, 30-days post-LT RRT was more common in AAH_HRS than in A-CLD_HRS (p = 0.08). Logistic regression showed that AAH_HRS conferred a 20× and 3.3× odds of requiring ⩾30 days post-LT RRT compared to CLD_{no HRS} and CLD_HRS, respectively. Postoperative complications were similar across cohorts, but had a significant effect on 30-day renal outcome post-LT.

Conclusions: Patients with AAH were more likely to develop HRS and require RRT pre- and post-LT at our center. The etiology of hepatic decompensation and postoperative complications affect renal recovery post-LT. The systemic inflammation of AAH in addition to conditions favoring renal hypoperfusion may contribute to the unfavorable outcomes of HRS-AKI after LT in this patient population.

Keywords: acute alcohol-associated hepatitis; chronic liver disease; hepatorenal syndrome–acute kidney injury; inflammation; liver transplantation; patient outcomes; renal replacement therapy.