Pre-liver transplant (LT) renal dysfunction is associated with poor post-LT survival. We aimed to study whether early allograft dysfunction (EAD) modifies the negative impact of pre-LT renal dysfunction on post-LT survival.
Data on 2,856 primary LT recipients transplanted between 1998 and 2018 were retrospectively reviewed. Patients who died within the first post-LT week, multi-organ transplant, and previous LT recipients were excluded. EAD was defined as 1) total bilirubin ≥10 mg/dl on POD 7, 2) international normalized ratio ≥1.6 on POD 7, and/or 3) alanine aminotransferase or aspartate aminotransferase ≥2000IU/mL in the first postoperative week. Pre-LT renal dysfunction was defined as serum creatinine >1.5mg/dl or on renal replacement therapy at LT. Patients were divided into 4 groups according to pre-LT renal dysfunction and post-LT EAD development.
Recipients who had both pre-LT renal dysfunction and post-LT EAD had the worst unadjusted 1, 3, and 5-year post-LT patient and graft survival while patients who had neither renal dysfunction nor EAD had the best survival (P<0.001). Patients with either EAD or renal dysfunction had intermediate survival. After adjusting for multiple factors, the risk of death was significantly higher only in those with both pre-LT renal dysfunction and post-LT EAD (aHR 2.32, CI: 1.68-3.21, P<0.001) while those with renal dysfunction and no EAD had a comparable risk of death to those with normal kidney function at LT (aHR 1.24; CI: 0.96-1.58, P=0.094). Results remained unchanged when pre-LT renal dysfunction was redefined using different glomerular filtration rate cut-offs.
Pre-LT renal dysfunction negatively impacts post-LT survival only in patients who develop EAD. Livers at higher risk of post-LT EAD should be used with caution in recipients with pre-LT renal dysfunction.

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