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

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 or CLD. CLD was categorized by disease etiology: cirrhosis due to alcohol (A-CLD) cirrhosis from other causes (O-CLD). CLD patients without HRS-AKI were labeled CLD.

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 63.8%,  = 0.04). For the primary outcome, AAH subjects required ⩾30 days post-LT renal replacement therapy (RRT) more often than subjects with CLD ( = 0.02) and CLD ( < 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 than in A-CLD ( = 0.08). Logistic regression showed that AAH conferred a 20× and 3.3× odds of requiring ⩾30 days post-LT RRT compared to CLD and CLD, 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.