Continued Influence of Preoperative Renal Function on Outcome of Orthotopic Liver Transplant (OLTX) in the US: Where Will MELD Lead Us?

Department of Transplantation, Mayo Clinic Jacksonville, Jacksonville, Florida, USA.
American Journal of Transplantation (Impact Factor: 5.68). 12/2006; 6(11):2651-9. DOI: 10.1111/j.1600-6143.2006.01526.x
Source: PubMed


Renal function is a component of the Model for End Stage Liver Disease (MELD), We queried the 1999-2004 OPTN/UNOS database to determine whether preoperative renal function remained an important determinant of survival in primary deceased donor liver transplant alone patients (DDLTA) or primary combined kidney liver transplant patients (KLTX). We examined preoperative creatinine, renal replacement therapy (RRT), incidence of KLTX, and patient survival in the 34 months before and after introduction of MELD and performed a multivariate Cox regression analysis of time to death. Preoperative renal function is an independent predictor of survival in DDLTA but not in KLTX. When compared to DDLTA with a preoperative serum creatinine of 0-0.99 mg/dL, patients with serum creatinine from 1-1.99 mg/dL, >2.0 mg/dL, those requiring RRT, and those receiving KLTX had a relative risk of death following transplant of 1.11, 1.58, 1.77, and 1.44 respectively. KLTX requiring RRT had better survival than DDLTA requiring RRT. Since introduction of MELD, KLTX, preoperative creatinine, and number of patients requiring preoperative RRT have increased. Despite this, patient survival following orthotopic liver transplant (OLTX) in the 34 months after introduction of MELD is not different than prior to introduction of MELD.

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Available from: Martin L Mai, Sep 18, 2014
    • "In 2002, the Model for End-Stage Liver Disease (MELD) scoring system was developed to give higher priority to liver transplant candidates who have cirrhosis and renal dysfunction. Since then, the number of patients with renal failure who undergo liver transplantation has increased , and the percentage of patients on RRT who received transplants also increased substantially [4]. In addition, the widespread availability of continuous RRT led to increased uses of RRT in patients with advanced liver failure as well, given the advantages of better control of hemodynamic instability and decreased risk of elevated intracranial pressure in these patients. "
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    ABSTRACT: Utilization of renal replacement therapy (RRT) in cirrhotic patients has been controversial and is typically dependent on the status of transplantation. A better understanding of the central role for arterial vasodilatation in the pathogenesis of hepatorenal syndrome (HRS) has led to routine use of vasoconstrictors in combination with albumin as a medical therapy for HRS with prolonged patient survival. The role of RRT in HRS patients receiving such treatment, however, has not yet been examined. A total of 80 patients with type 1 HRS who received a combination therapy of vasoconstrictors and albumin were enrolled into a retrospective cohort study. The effects of RRT status on clinical outcome were analyzed. Both short-term (30 days) and long-term (180 days) survival was similar between RRT and non-RRT groups of patients, but the length of hospital stay was significantly longer among patients in the RRT group, which remain unchanged despite adjustment of status for liver transplantation. Based on our observation, routine use of RRT may not be beneficial in patients with type 1 HRS receiving combination treatment of vasoconstrictor plus albumin. Further prospective studies are needed to validate these findings and refine the specific indications for RRT in this patient population. Copyright © 2015. Published by Elsevier Inc.
    No preview · Article · May 2015 · Journal of critical care
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    • "There are several studies reporting a worse outcome of liver transplantation in patients with kidney dysfunction and dialysis [30-32]. The registry data of liver transplant patients with postoperative kidney dysfunction demonstrate a significantly worse 2-year survival compared with patients with adequate or mild kidney dysfunction (55% vs. 76%, p < 0.05) [33]. "
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    ABSTRACT: Infections after liver transplantation are the main cause of death in the first year. Recent reports indicate that NOD2 gene mutations increase the risk for inflammatory bowl disease and the severity of graft-versus-host disease in bone marrow transplant patients. Data on polymorphisms in liver transplant patients are sparse. We analyzed 13 single-nucleotide polymorphisms (SNPs) of 13 different gene variants including the SNPs of NOD2 genes from liver recipients. The aim of the study was to evaluate the impact of the SNPs on dialysis-dependent kidney failure, the incidence of infections and patient survival. During a period of 20-months, 231 patients were recruited in this non-interventional, prospective study. Thirteen different SNPs and their impact on the patients' survival, infection rate, and use of dialysis were assessed. NOD 2 wildtype genes were protective with respect to the survival of non-alcoholic, cirrhotic transplant patients (3 year survival: 66.8% wildtype vs. 42.6% gene mutation, p = 0.026). This effect was not observed in alcoholic transplant recipients.The incidence of dialysis-dependent kidney failure and infection in the liver transplant patients was not influenced by NOD 2 gene polymorphisms. No effect was noted in the remaining 12 SNPs.Patients with early allograft dysfunction experienced significantly more infections, required dialysis and had significantly worse survival.In contrast, the donor-risk-index had no impact on the infection rate, use of dialysis or survival. NOD2 gene variants seem to play a key role in non-alcoholic, liver transplant recipients. However these data should be validated in a larger cohort.
    Full-text · Article · Jan 2014 · BMC Gastroenterology
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    • "Renal dysfunction occurs commonly in patients with end-stage liver disease (ESLD) awaiting orthotopic liver transplantation (OLT) [1,2]. In the MELD (Model End-Stage Liver Disease) scoring era, the use of simultaneous liver-kidney transplantation (SLKT) has increased [3,4]. From a renal standpoint, considerable uncertainty remains as to which patients will benefit from SLKT [4]. "
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    ABSTRACT: Renal dysfunction occurs commonly in patients awaiting orthotopic liver transplantation (OLT) for end-stage liver disease. The use of simultaneous liver-kidney transplantation has increased in the MELD scoring era. As patients may recover renal function after OLT, identifying factors predictive of renal recovery is a critical issue, especially given the scarcity of available organs. Employing the UNOS database, we sought to identify donor- and patient-related predictors of renal recovery among 1720 patients with pre-OLT renal dysfunction and transplanted from 1989 to 2005. Recovery of renal function post-OLT was defined as a composite endpoint of serum creatinine (SCr) <=1.5 mg/dL at discharge and survival >=29 days. Pre-OLT renal dysfunction was defined as any of the following: SCr >=2 mg/dL at any time while awaiting OLT or need for renal replacement therapy (RRT) at the time of registration and/or OLT. Independent predictors of recovery of renal function post-OLT were absence of hepatic allograft dysfunction, transplantation during MELD era, recipient female sex, decreased donor age, decreased recipient ALT at time of OLT, decreased recipient body mass index at registration, use of anti-thymocyte globulin as induction therapy, and longer wait time from registration. Contrary to popular belief, a requirement for RRT, even for prolonged periods in excess of 8 weeks, was not an independent predictor of failure to recover renal function post-OLT. These data indicate that the duration of renal dysfunction, even among those requiring RRT, is a poor way to discriminate reversible from irreversible renal dysfunction.
    Full-text · Article · Jul 2013 · BMC Nephrology
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