The progression of hepatorenal syndrome–acute kidney injury in acute alcohol-associated hepatitis: renal outcomes after liver transplant

BACKGROUND: Hepatorenal syndrome–acute kidney injury (HRS-AKI) is a complication of advanced liver disease in patients with ascites and circulatory dysfunction. Little data remain on the relationship between HRS-AKI outcomes and different etiologies of liver disease post-liver transplant (LT). OBJECTIVES: The primary aim was to evaluate the effect of HRS-AKI on renal outcomes in patients with acute alcohol-associated hepatitis (AAH) compared to chronic liver disease (CLD) after LT. The secondary aim was to evaluate the impact of acuity and chronicity of alcohol-associated liver disease in patients with HRS-AKI post-LT renal outcomes. DESIGN: A retrospective observational study of patients undergoing urgent inpatient liver transplant evaluation (LTE) for cirrhosis and AAH at single academic LT center between October 2017 and July 2021 was conducted. METHODS: Patients with HRS-AKI were selected based on indication for LTE: acute AAH(HRS) or CLD(HRS). CLD(HRS) was categorized by disease etiology: cirrhosis due to alcohol (A-CLD(HRS)) versus cirrhosis from other causes (O-CLD(HRS)). CLD patients without HRS-AKI were labeled CLD(no HRS). RESULTS: A total of 210 subjects underwent LTE; 25% were evaluated for AAH and 75% were evaluated for CLD. Hepatorenal syndrome was more common in subjects evaluated for AAH (37/47) than CLD (104/163) (78.7 versus 63.8%, p = 0.04). For the primary outcome, AAH(HRS) subjects required ⩾30 days post-LT renal replacement therapy (RRT) more often than subjects with CLD(HRS) (p = 0.02) and CLD(no HRS) (p < 0.01). There was no significant difference in other forms of long-term renal outcomes including kidney transplant referral and kidney transplant among cohorts. In subgroup analysis, 30-days post-LT RRT was more common in AAH(HRS) than in A-CLD(HRS) (p = 0.08). Logistic regression showed that AAH(HRS) conferred a 20× and 3.3× odds of requiring ⩾30 days post-LT RRT compared to CLD(no HRS) and CLD(HRS), respectively. Postoperative complications were similar across cohorts, but had a significant effect on 30-day renal outcome post-LT. CONCLUSIONS: Patients with AAH were more likely to develop HRS and require RRT pre- and post-LT at our center. The etiology of hepatic decompensation and postoperative complications affect renal recovery post-LT. The systemic inflammation of AAH in addition to conditions favoring renal hypoperfusion may contribute to the unfavorable outcomes of HRS-AKI after LT in this patient population.