Beginning Kidney Replacement Therapy Before or After Liver Transplantation: Does the Timing of Dialysis Matter? A...

Acute kidney injury (AKI) in liver transplant patients is associated with increased morbidity, mortality, and reduced graft survival. However, the impact of the timing of dialysis initiation-before versus after transplantation-remains unclear.

To characterize liver transplant recipients with Kidney Disease: Improving Global Outcomes (KDIGO) Stage 3 AKI-requiring dialysis (AKI-D) according to the timing of kidney replacement therapy (KRT) initiation (pre- versus posttransplant) and to evaluate 90-day mortality. Secondary objectives included identifying independent predictors of dialysis dependence and assessing liver graft function at 90 days.

This retrospective, single-center cohort study included all consecutive adult liver transplant recipients who received dialysis in a Brazilian intensive care unit (ICU) between 1999 and 2015. The study was approved by the Research Ethics Committee of the Federal University of Sao Paulo (UNIFESP), with a waiver of informed consent. Patients were grouped according to the timing of dialysis initiation: pre- or postliver transplantation. Multiple logistic regression was used to identify predictors of 90-day mortality and dialysis dependence. Ninety-day liver graft survival was analyzed using a multivariate Cox model.

A total of 356 liver transplant patients with AKI-D were included. Of these, 109 (30.6%) initiated dialysis within 4 weeks before transplantation and 247 (69.4%) within 4 weeks after transplantation. The timing of dialysis initiation was not associated with 90-day mortality or dialysis dependence. Independent predictors of 90-day mortality included graft dysfunction and use of continuous KRT as the initial modality. Impaired pretransplant renal function and a history of diabetes mellitus were predictors of 90-day dialysis dependence. Posttransplant dialysis was associated with a twofold increased risk of liver graft failure.

The timing of dialysis initiation (pre- versus posttransplantation) was not associated with 90-day mortality or dialysis dependence. However, initiation of dialysis after transplantation was associated with an increased risk of liver graft dysfunction.