Drs.  Gina Iacovella and Neelja Kumar (GI&NK), from Yale University Medical Center, discuss their abstract for the National Kidney Foundation’s 2014 Spring Clinical Meetings (SCM14), Mortality of Patients with Significant Liver Dysfunction Initiated on Dialysis, with Dr. Kenar Jhaveri (eAJKD), eAJKD Editor.

eAJKD: Why don’t you tell us a little about your research and abstract being presented at NKF 2014 Spring Meetings?

GI&NK: We practice nephrology at a tertiary medical care center in the East Coast where we encounter a large cohort of liver failure patients.  The average MELD score of these patients prior to transplant is >30, representing a population with increased morbidity and mortality.  Our Nephrology consult team is often asked to help manage these patients with decompensated cirrhosis or severe, acute hepatitis and new on-set acute kidney injury and metabolic derangements. Frequently these patients have not undergone liver transplant evaluation prior to their renal function decline and the question of dialysis initiation is posed. Therefore, we decided to perform an observational, retrospective study to evaluate the efficacy of dialysis initiation in patients with significant liver dysfunction who were not listed for orthotopic liver transplant ( OLTx) at the time of admission.

eAJKD: Based on your study findings, would you prefer a palliative approach to AKI in patients with significant liver dysfunction rather than dialysis?

GI&NK: Based on our results, if patients were successfully listed for OLTx after initiation of dialysis there was a 88% chance of survival, whereas survival of patients who were never listed for transplant was only 4%. Given these grim statistics, it is important to begin the process of evaluation for liver transplantation as soon as possible once AKI is diagnosed. Because liver transplant evaluation is a complex process, it is important to discuss expectations with the patient and family at an early time in the process, and it may be prudent to consider a trial of dialysis for a predefined amount of time while the transplant evaluation is underway, and transition to a palliative approach if the patient has decompensated cirrhosis and is not a candidate for OLTx. It is important to note that the small number of patients in our study who exhibited acute decompensation of liver function with AKI in the absence of severe underlying cirrhosis had a better overall survival, and thus we feel that these patients warrant dialysis intervention if medically appropriate.

It has been suggested that patients who develop ATN, a potentially reversible cause of AKI, should be candidates for dialysis irrespective of transplant status. However, we found that the overall mortality of patients who were not listed for OLTx was not improved in those judged to have ATN as compared to those identified as having HRS.

eAJKD: Where do you and your group go from here?

GI&NK: We hope that our study initiates a discussion across multiple disciplines regarding future management of patients with end stage liver disease who develop renal failure, and leads to a larger, multicenter study to determine if our results are representative of those at other transplant centers.  Based on our single center study, it appears that it would be in the patient’s best interest to undergo an expedited workup and be listed for OLTx if appropriate. In this subgroup of patients, we believe that initation of dialysis is a reasonable option. However, in patients who are found to not be candidates for OLTx, significant consideration should be given to palliative measures and a thoughtful discussion of the risks and benefits of dialysis should occur with both the patient and amongst the multidisciplinary team caring for the patient.  It is an unfortunate reality that overwhelming morbidity and mortality is associated with dialysis in the setting of significant liver dysfunction, and every effort should be made to improve outcomes and provide patients with care that is beneficial without unnecessarily prolonging suffering in cases where survival is unrealistic.

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