Author information

¹Department of Gastroenterology, Hepatology & Nutrition, Center for Liver Disease, University of Chicago Medicine, Chicago, IL, USA.

²Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.

³MGH Biostatistics, Massachusetts General Hospital, Boston, MA, USA.

⁴Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA.

⁵Division of Gastroenterology and Hepatology, University of South Carolina School of Medicine, Columbia, SC, USA.

⁶Gastrointestinal Unit, Gastrointestinal Division, Department of Medicine, Liver Center, Massachusetts General Hospital, Boston, MA, USA.

⁷Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.

⁸Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.

⁹Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA.

¹⁰Division of Nephrology, UMass Memorial Medical Center, Worcester, MA, USA.

¹¹Divisions of Nephrology and Palliative Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA.

¹²Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA.

¹³Gastrointestinal Unit, Gastrointestinal Division, Department of Medicine, Liver Center, Massachusetts General Hospital, Boston, MA, USA. nneka.ufere@mgh.harvard.edu.

Abstract

Background: Data to guide dialysis decision-making for transplant-ineligible patients with cirrhosis are lacking.

Aims: We aimed to describe the processes, predictors, and outcomes of renal replacement therapy (RRT) initiation for transplant-ineligible patients with cirrhosis at a single liver transplantation center.

Methods: We conducted a mixed-methods study of a retrospective cohort of 372 transplant-ineligible inpatients with cirrhosis with acute kidney injury (AKI) due to hepatorenal syndrome (HRS-AKI) or acute tubular necrosis (ATN) between 2008 and 2015. We performed survival analyses to evaluate 6-month survival and renal recovery and examined end-of-life care outcomes. We used a consensus-driven medical record review to characterize processes leading to RRT initiation.

Results: We identified 266 (71.5%) patients who received RRT and 106 (28.5%) who did not receive RRT (non-RRT). Median survival was 12.5 days (RRT) vs. 2.0 days (non-RRT) (HR 0.36, 95%CI 0.28-0.46); 6-month survival was 15% (RRT) vs. 0% (non-RRT). RRT patients were more likely to die in the intensive care unit (88% vs. 32%, p < 0.001). HRS-AKI patients were more likely to be RRT dependent at 6 months than ATN patients (86% vs. 27%, p = 0.007). The most common reasons for RRT initiation were unclear etiology of AKI on presentation (32%) and belief of likely reversibility of ATN (82%).

Conclusion: Most transplant-ineligible patients who were initiated on RRT experienced very short-term mortality and received intensive end-of-life care. However, approximately 1 in 6 were alive at 6 months. Our findings underscore the critical need for structured clinical processes to support high-quality serious illness communication and RRT decision-making for this population.