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Beginning Kidney Replacement Therapy Before or After Liver Transplantation: Does the Timing of Dialysis Matter? A Cohort Study

Year: 2026

Type: article

Abstract: Introduction: Acute kidney injury (AKI) in liver transplant patients is associated with increased morbidity, mortality, and reduced graft survival. However, the impact of the timing of dialysis initiation-before versus after transplantation-remains unclear. Objectives: To characterize liver transplant recipients with Kidney Disease: Improving Global Outcomes (KDIGO) Stage 3 AKI-requiring dialysis (AKI-D) according to the timing of kidney replacement therapy (KRT) initiation (pre- versus posttransplant) and to evaluate 90-day mortality. Secondary objectives included identifying independent predictors of dialysis dependence and assessing liver graft function at 90 days. Methods: This retrospective, single-center cohort study included all consecutive adult liver transplant recipients who received dialysis in a Brazilian intensive care unit (ICU) between 1999 and 2015. The study was approved by the Research Ethics Committee of the Federal University of Sao Paulo (UNIFESP), with a waiver of informed consent. Patients were grouped according to the timing of dialysis initiation: pre- or postliver transplantation. Multiple logistic regression was used to identify predictors of 90-day mortality and dialysis dependence. Ninety-day liver graft survival was analyzed using a multivariate Cox model. Results: A total of 356 liver transplant patients with AKI-D were included. Of these, 109 (30.6%) initiated dialysis within 4 weeks before transplantation and 247 (69.4%) within 4 weeks after transplantation. The timing of dialysis initiation was not associated with 90-day mortality or dialysis dependence. Independent predictors of 90-day mortality included graft dysfunction and use of continuous KRT as the initial modality. Impaired pretransplant renal function and a history of diabetes mellitus were predictors of 90-day dialysis dependence. Posttransplant dialysis was associated with a twofold increased risk of liver graft failure. Conclusion: The timing of dialysis initiation (pre- versus posttransplantation) was not associated with 90-day mortality or dialysis dependence. However, initiation of dialysis after transplantation was associated with an increased risk of liver graft dysfunction.

Source: Journal of Transplantation

DOI: 10.1155/joot/6880648