RENAL REPLACEMENT THERAPY AND ORTHOTOPIC LIVER TRANSPLANTATION: THE ROLE OF CONTINUOUS VENO-VENOUS HEMODIALYSIS 1


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Abstract

Background.The need for renal replacement therapy (RRT) either beforeor after orthotopic liver transplant (OLTX) has been reported to be a poorprognostic indicator for survival. Use of continuous veno-venous hemodialysis(CVVHD) for RRT has been reported in three series of OLTX patients with high90-day mortality rates of 57–60%. We have examined our patientpopulation to determine the effect of necessity and type of RRT on patientsurvival afterOLTX.Methods.We analyzed 1535 OLTX that were performed at ourinstitution from 1985 through 1999, 1037 from 1985 to 1995 (period I) and 498from 1996 to 1999 (period II). Combined liver-kidney transplants were excludedfrom analysis. Hospital dialysis unit records and a prospectively maintaineddatabase on all OLTX patients served as the source of data. Patients wereclassified into groups defined on whether or not they received RRT, when theyreceived RRT, and the type of RRT. Groups were compared for preoperativeintensive care unit status, time on the waiting list, laboratory variables,90-day postoperative mortality, 1-year patient survival, and absolutesurvival.Results.Use of RRT increased from 8.29% in period I to 12.45% inperiod II, along with increased median waiting times. In period I, patientsreceiving preoperative RRT had a 90-day mortality (0%) and a 1-year survival(89.5%) almost identical to those patients who never required RRT (1.7% and90.6%). Patients who developed acute renal failure postoperatively requiringRRT, however, had a 90-day mortality of 28.6% and a 1-year survival of 55%. Inperiod II, patients requiring RRT had a 90-day mortality of 39.7% and a 1-yearactuarial survival of 54.5% compared with 6.9% and 88.6% in patients neverrequiring RRT. Patients treated with CVVHD had a 90-day mortality of 42%compared with 25% in patients treated with hemodialysis alone. However,patients receiving CVVHD both pre- and postoperatively had a 90-day mortalityof 27.7% vs. 50% in those patients who only received CVVHD postoperatively.Patients who developed acute renal failure postoperatively, which requiredRRT, regardless of therapy, had a 1-year survival of only 41.0% compared witha 1-year survival of 73.6% in those patients started on RRT preoperatively, P =0.03.Conclusions.The need for RRT has increased along with waiting time inOLTX patients. Patients developing the need for RRT postoperatively have anincreased 90-day mortality and lower 1-year survival with the highest beingpresent in patients receiving CVVHD, which was started postoperatively. Thesefindings may reflect a trend toward a sicker population awaiting OLTX andemphasize the negative impact of renal failure on survival afterOLTX.

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