Impact of Advanced Renal Dysfunction on Posttransplant Outcomes After Living Donor Liver Transplantation in the United States.

BACKGROUND Survival after living donor liver transplantation (LDLT) in the U.S. is excellent. However, the significance of pretransplant kidney disease on outcomes in this population is poorly understood. METHODS This was a retrospective cohort study of 2806 LDLT recipients nationally between 1/2010-6/2020. Recipients with estimated glomerular filtration rate <40mL/min/1.73m2 (eGFR-low) or requiring dialysis were compared. Multivariable survival analyses evaluated (i) eGFR-low as a predictor of post-LDLT survival, (ii) the survival of LDLT versus deceased donor liver transplant (DDLT) alone with eGFR-low. RESULTS From 2010-2020, 140 (5.0%) patients had eGFR-low and 18 (0.6%) required dialysis pre-LDLT. The number of LDLTs requiring dialysis between 2017-2020 outnumbered the prior 7 years. Overall LDLT experience was greater at centers performing LDLT in recipients with renal dysfunction (p<0.001). LDLT recipients with eGFR-low had longstanding renal dysfunction: mean eGFR 3-6 months prior to LDLT 42.7 (±15.1) mL/min/1.73m2. Nearly half (5/12) of eGFR-low recipients with active kidney transplant (KT) listing at LDLT experienced renal recovery. Five patients underwent early KT after LDLT via the new 'safety net' policy. Unadjusted survival after LDLT was worse with eGFR-low (HR 2.12 vs eGFR ≥40mL/min/1.73m2, 95% CI: 1.47-3.05; p<0.001), but no longer so when accounting for mean eGFR 3-6 months pre-LDLT (HR 1.27, 95% CI: 0.82-1.95; p=0.3). The adjusted survival of patients with eGFR-low receiving LDLT versus DDLT alone was not different (p=0.08). CONCLUSIONS Overall, outcomes after LDLT with advanced renal dysfunction are acceptable. These findings are relevant given the recent 'safety net' KT policy.Supplemental Visual Abstract; http://links.lww.com/TP/C173.