M. Selim1, M. Zimmerman1, J. Kim1, K. Regner2, D. C. Cronin1, K. Saeian3, L. A. Connolly4, K. K. Lauer4, H. J. Woehlck4, J. C. Hong1 1Medical College Of Wisconsin,Division Of Transplant Surgery/Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Division Of Nephrology/Department Of Medicine,Milwaukee, WI, USA 3Medical College Of Wisconsin,Division Of Gastroenterology And Hepatology/Department Of Medicine,Milwaukee, WI, USA 4Medical College Of Wisconsin,Department Of Anesthesiology,Milwaukee, WI, USA
Introduction: The Model of End Stage Liver Disease (MELD) scoring system (ranges between 6 to > 40) is an accurate predictor of pretransplant mortality. Liver transplantation (LT) in critically ill patients with end-stage liver disease (MELD > 35) and concomitant renal failure carries a high intraoperative and immediate post-transplant risk. Intraoperative hemodialysis (IOHD) has been utilized to aid these patients undergoing LT. We sought to analyze outcomes after LT for patients requiring IOHD.
Methods: A retrospective analysis from our prospective database of 82 adult LTs between October 2012 and August 2015. The median follow up was 12 months.
Results: Among those 82 LTs, 37 (45.1%) patients had a MELD score > 35. Thirty-three patients had pre-LT renal dysfunction: 25 (76%) underwent IOHD (Grp I) and 8 (24%) did not (Grp II). Hepatitis C and alcohol were the commonest etiologies for liver failure. While the mean MELD scores were comparable between groups I (43 + 5) and II (41 + 5), patients in Grp I were acutely ill compared to Grp II: there was a higher need for ICU management and urgent HD prior to LT (96% in Grp I versus 50% in Grp II, p=0.002), and an increased requirement for immediate post-transplant HD (92% in Grp I versus 50% in Grp II, p=0.007). In Grp I, 48% received a combined liver-kidney transplant (CLK) compared to 87.5% in Grp II, p=0.04. Among those who are alive at 3 months posttransplant, the HD-free recovery of renal function was 100% in Grp I and 75% in Grp II, p= 0.018. The organ preservation ischemic times and intraoperative blood transfusion requirement were comparable for both groups. There was a trend towards a lower intraoperative post-liver reperfusion hemodynamic instability in Grp I (16%) versus Grp II (37.5%), p=0.19. Post LT patient and graft survival rates were comparable for Grp I and Grp II at 30 days (88% vs. 100%) and at 6 months (84% vs. 100%), p=0.14.
Conclusions: IOHD is a safe therapeutic adjunct during LT of patients with the highest acuity. Identifying patients who require IOHD would improve intraoperative and post-LT survival outcomes and may facilitate recovery of post-LT renal function.