Introduction

Renal dysfunction in the presence of end stage liver disease (ESLD) has been associated with increased morbidity and mortality post liver transplant (LT). In the presence of concomitant renal disease, pre-LT renal replacement therapy (RRT) has demonstrated improved outcomes post-LT. However, the role of RRT prior to LT in patients without renal disease is arguable.

Aims & Methods

In this study, we aimed to study the outcomes of RRT initiated pre-LT in patients awaiting LT without renal disease. US nationwide readmission database (NRD 2016 to 2019) was used. Hospitalizations that underwent RRT before liver transplant (cases) were identified using the database. A matched comparison cohort of similar hospitalizations who did not undergo RRT before liver transplant (controls) was identified from NRD after 1:1 propensity score matching.
After identifying the index admission from NRD, we calculated the time to RRT and time to LT using procedure codes and study patients were included only if time to RRT was less than time to LT, thereby correctly identifying patients who had RRT pre-LT. Inpatient clinical outcomes, mortality and survival estimates were calculated and compared. Hospitalizations with age<18 years, end-stage renal disease (ESRD) or CKD stage IV, renal transplant were excluded from the analysis.

Results

728 patients were included. We matched 364 hospitalizations with RRT before LT (cases) to 364 hospitalizations with no RRT before LT (controls). Adequate comorbidity balance was achieved with propensity matching between the comparison groups, including CKD (stage I - III), obesity, fluid & electrolyte disorder. The median age was 51.5 years in cases (IQR 43-59) and 54 years in controls (IQR 46-61). The time to liver transplant was longer in patients with pre-LT RRT as compared to no RRT before LT [13.5 days (IQR 8-20) vs 1 day (IQR 0-8), P<0.001].
There was no statistical difference in all-cause inpatient mortality between cases and controls (4.9% vs. 3.6%, P=0.4). Pre-LT RRT was associated with longer length of stay, 32 days (IQR 22-46) compared to 14 days (IQR 9-30) (P<0.001) in patients without pre-LT RRT. Additionally, the median total hospital charges were also higher in pre-LT RRT [$827,695 (IQR 574,184-1,354,623) vs $467,809 (IQR 323,809-724,291), P<0.001].
A significantly greater proportion of patients with RRT prior to LT were associated with mechanical ventilation (43.7% vs. 16.2%, OR 4.0 [2.8- 5.7], P<0.001), septic shock (44.8% vs. 21.4%, OR 2.9 [2.1- 4.1], P<0.001), ICU admission (40.7% vs. 17.0%, OR 3.3 [2.4- 4.7], P<0.001), vasopressor requirement (23.9% vs. 14.3%, OR 1.9 [1.3 - 2.8], P<0.001) and acute kidney injury (95.6% vs. 75.8%, OR 6.9 [3.9 - 12.1], P <0.001) as compared to controls. RRT requirement post LT was significantly greater in cases vs controls (100% vs 17%, P<0.001).
There was no difference in transplant rejection (5.2% vs 6%, p=0.6), risk of inpatient mortality at 30-day (HR 1.06 [0.4-2.6], P=0.9), 60-day (HR 0.85 [0.4-1.8], P=0.7) or 90-day intervals (HR 0.79 [0.4-1.6], P=0.5) (Figure 2) between the groups. 180-days Kaplan-Meier survival estimates were comparable as well (P=0.5).

Conclusion

Based on this study, RRT prior to LT was associated with greater instances of ICU related treatment, AKI and need for RRT post-LT. LT rejection, 30-day, 60-day and 90-day inpatient mortality were similar, along with comparable 180-day survival estimates. Results seem to suggest RRT is better avoided in pre-LT setting in the absence of renal dysfunction. Longitudinal studies are warranted to establish causality.

Introduction

The clinical value of combined resection of important hepatic vessels in hilar cholangiocarcinoma remains controversial. We aimed to compare the short-term and long-term outcome of combined versus non-combined major vessel resection in patients undergoing radical resection for hilar cholangiocarcinoma.

Aims & Methods

This single centre retrospective cohort study of patients with hilar cholangiocarcinoma was conduct from January 2007 to December 2018. Patients who underwent radical re-resection were enrolled. The short-term and long-term clinical outcomes of the groups were compared after propensity score matching.

Results

A total of 310 patients were included. There was no statistically significant difference in perioperative clinical outcomes between VR group (PVR and AVR) and non-VR group after 1:2 PSM. Patients who received PVR had significantly longer OS (p=0.023) and DFS (p=0.010) compared to those in the non-PVR group. AVR group was associated with improved OS (p=0.036) and DFS (p=0.029) compared with non-AVR group following the curative-intent resection. The postoperative complications of combined VR would not worsen long-term survival for patients (OS: p=0.159; DFS: p=0.112).

Conclusion

Combined vascular resection (VR) would improve the long-term survival for patients with hilar cholangiocarcinoma. The postoperative complications of combined VR would not worsen long-term survival. Therefore, radical surgical resection should be actively performed in these patients.

Disclosure

The authors declare that they have no competing interests.