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

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.