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BOSTON -- For patients with cirrhosis waitlisted for liver transplant who were hospitalized with acute kidney injury (AKI), 90-day survival outcomes were improved with AKI response, according to the results of a retrospective study presented here.

Of the patients with AKI response, 89.4% were alive at 90 days compared with 76.2% who did not respond (HR 0.34, 95% CI 0.18-0.65, P=0.001), reported Xing Li, MD, MBA, of Massachusetts General Hospital in Boston.

Responders also had significantly improved 90-day transplant-free survival (63.5% vs 25.2%, respectively; HR 0.35, 95% CI 0.25-0.50, P<0.001), she said during a presentation at the American Association for the Study of Liver Diseases annual meeting.

"This suggests a substantial protective effect of AKI response," and "really reinforces the importance of promptly recognizing and treating AKI, regardless of etiology, and with appropriate medical therapy, in this patient population," Li noted.

While AKI is common in patients with cirrhosis and associated with poor prognosis, AKI response or recovery is linked with improved survival. However, according to Li, for patients on the liver transplant waitlist, it is unclear how AKI response affects transplant rates and timing.

She also noted that with the approval of terlipressin (Terlivaz) for adults with hepatorenal syndrome and rapidly deteriorating kidney function, "there have been some concerns raised about how its use may negatively affect the priority of patients awaiting liver transplant."

"Therefore, there is a need to get a better baseline understanding of how AKI response in general affects the outcomes of patients awaiting liver transplant," she said.

This analysis included 317 consecutive patients with cirrhosis waitlisted for liver transplant who had been hospitalized with AKI in 2019 at 11 U.S. transplant centers. Of these patients, 170 responded to medical management (a decrease in serum creatinine to within 0.3 mg/dL of baseline or regression of AKI stage), and 147 did not.

Baseline demographics and clinical characteristics were similar between the two groups, with the exception that responders had lower Model for End-Stage Liver Disease (MELD) scores (a median of 28 vs 31 for nonresponders).

Li and her colleagues also observed that responders had a lower 90-day probability of transplant compared with nonresponders (45.9% vs 61.2%; HR 0.55, 95% CI 0.37-0.84, P=0.005).

"How we interpreted this finding is that there was likely a subset of patients whose AKI resolved or improved during hospitalization and did not need transplant in the short-term period," Li said. "However, there were also about 45% of responders who eventually did require transplant, and that really outlines the importance of close outpatient monitoring of these patients, even after AKI recovery."

The majority (79%) of liver transplants in responders occurred after discharge, at a median of 103 days, while the majority (62%) of transplants in non-responders occurred during the same hospitalization, with the remainder occurring post-discharge at a median of 57.5 days.

Compared with non-responders, responders also had shorter hospital and intensive care unit (ICU) lengths of stay by a median of 10 and 6 days, respectively, and smaller proportions of responders required ICU admission, intubation, renal replacement therapy, and vasopressor use.

A sensitivity analysis within the subpopulation of 180 patients who received vasoconstrictor therapy yielded similar results for 90-day mortality, 90-day transplant-free survival, and 90-day probability of transplant.

During a Q&A session following the presentation, Josh Levitsky, MD, of Northwestern University Feinberg School of Medicine in Chicago, said that while the study clearly demonstrated that survival and other critical outcomes were improved pre-transplant, the "elephant in the room" is the delay in transplantation, which patients who are waitlisted ultimately need. "Is there absolutely no data on anything post-transplant?" he asked.

Li acknowledged that a limitation of the study was that it lacked data on longer-term outcomes, and that a next step will be an analysis of post-transplant outcomes, "and perhaps a longer-term follow-up -- instead of 90 days, more like 1 year."

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