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Living donor liver transplantation for hepatorenal syndrome: To do or not to do? That is the question
Author(s) -
Nadim Mitra K.,
Sung Randall S.
Publication year - 2012
Publication title -
liver transplantation
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.814
H-Index - 150
eISSN - 1527-6473
pISSN - 1527-6465
DOI - 10.1002/lt.23498
Subject(s) - hepatorenal syndrome , medicine , liver transplantation , liver disease , dialysis , acute kidney injury , transplantation , model for end stage liver disease , etiology , retrospective cohort study , context (archaeology) , population , intensive care medicine , surgery , cirrhosis , paleontology , environmental health , biology
Acute kidney injury (AKI) is common in patients with end-stage liver disease with an estimated prevalence of 20% at the time of liver transplantation (LT). The evolution of renal dysfunction in the context of liver failure ranges from insidious to rapid and from mild to severe. For patients who do not undergo LT, AKI is associated with a 90% in-hospital mortality rate. Therefore, the development of AKI adds an element of urgency for the patient and strategic complexity for the transplant program in making appropriate and timely decisions. Unfortunately, the utility of the current evidence is incomplete for defining appropriate management algorithms for this patient population. Studies in the published literature have usually been retrospective and single-center, and they have suffered from small sample sizes, reporting bias, and varying definitions of AKI; this makes study comparisons very difficult. The majority have demonstrated pretransplant AKI to be an independent predictor of post-LT mortality. However, these studies have failed to categorize patients according to the etiology of AKI. In a recent single-center, retrospective study, the etiology of AKI was shown to affect posttransplant outcomes: patients with hepatorenal syndrome (HRS) at the time of transplantation achieved survival outcomes similar to those of patients who had no AKI, regardless of the dialysis duration, the Model for End-Stage Liver Disease (MELD) score, or the Sequential Organ Failure Assessment score. The prognosis of patients with HRS and especially patients who develop type 1 HRS is extremely poor, and HRS is a terminal event for patients with advanced cirrhosis with a median survival of approximately 2 weeks. Therapies such as terlipressin and albumin dialysis provide only a modest survival benefit (if any), and the only chance for survival is LT. However, because of concerns about outcomes and ethical issues related to coercion and donor risk, many transplant centers have been reluctant to offer living donor liver transplantation (LDLT) to patients with high MELD scores, including patients with type 1 HRS. In this issue of Liver Transplantation, Chok et al. report the outcomes of patients with HRS who underwent LDLT or deceased donor liver transplantation (DDLT) at their institution. Seventy-one of 726 adult patients who underwent LT at a single center in Korea were considered to have had HRS at the time of transplantation, and 48 of these patients underwent LDLT. Although overall survival was lower for patients with HRS versus patients without HRS, the survival of LDLT recipients with HRS was better than or at least no worse than the survival of DDLT recipients with HRS. A subgroup analysis of patients with high MELD scores ( 30) and patients with type 1 HRS also demonstrated similar survival