Long-term renal outcomes comparison between patients with chronic kidney disease and hepatorenal syndrome after living donor liver transplantation.

Background and aims: Hepatorenal syndrome (HRS) is a disastrous renal complication of advanced liver disease with a poor prognosis. Restoring normal liver function through liver transplantation (LT) is a standardized treatment with favorable short-term survival. However, the long-term renal outcomes in patients with HRS receiving living donor LT (LDLT) are controversial. This study aimed to investigate the prognostic impact of LDLT in patients with HRS. Methods: We reviewed adult patients who underwent LDLT between July 2008 and September 2017. Recipients were classified into 1) HRS type 1 (HRS1, N = 11), 2) HRS type 2 (HRS2, N = 19), 3) non-HRS recipients with pre-existing chronic kidney disease (CKD, N = 43), and 4) matched normal renal function (N = 67). Results: Postoperative complications and 30-day surgical mortality were comparable among the HRS1, HRS2, CKD, and normal renal function groups. The 5-year survival rate was >90% and estimated glomerular filtration rate (eGFR) transiently improved and peaked at 4 weeks post-transplantation in patients with HRS. However, renal function deteriorated and resulted in CKD stage ≥ III in 72.7% of HRS1 and 78.9% of HRS2 patients (eGFR <60 ml/min/1.73 m2). The incidence of developing CKD and end-stage renal disease (ESRD) was similar between the HRS1, HRS2, and CKD groups, but significantly higher than that in the normal renal function group (both P < 0.001). In multivariate logistic regression, pre-LDLT eGFR <46.4 ml/min/1.73 m2 predicted the development of post-LDLT CKD stage ≥ III in patients with HRS (AUC = 0.807, 95% CI = 0.617-0.997, P = 0.011). Conclusions: LDLT provides a significant survival benefit for patients with HRS. However, the risk of CKD stage ≥ III and ESRD among patients with HRS was similar to that in pre-transplant CKD recipients. An early preventative renal-sparing strategy in patients with HRS is recommended.

From Death Triad to Death Tetrad-The Addition of a Hypotension Component to the Death Triad Improves Mortality Risk Stratification in Trauma Patients: A Retrospective Cohort Study.

The death triad, including coagulopathy, hypothermia, and acidosis, is shown to be a strong predictor of mortality in trauma patients. We aimed to investigate whether the inclusion of hypotension, defined as systolic blood pressure (SBP) < 60 mmHg, as a fourth factor in the death triad would comprise a death tetrad to help stratify mortality risk in trauma patients. A total of 3361 adult trauma patients between 1 January 2009 and 31 December 2019 were allocated into groups to investigate whether hypotension matters in determining the mortality outcome of trauma patients who possess 1−3 death triad components compared to those without any component. Hypotension was added to the death tetrad, and the adjusted mortality outcome was compared among groups with 0−4 death tetrad components. Herein, we showed that SBP < 60 mmHg could be used to identify patients at risk of mortality among patients with one or two death triad components. Patients with one, two, and three death tetrad components had respective adjusted mortality rates of 3.69-, 10.10-, and 40.18-fold, determined by sex, age, and comorbidities. The mortality rate of trauma patients with all the four death tetrad components was 100%. The study suggested that hypotension, defined as an SBP < 60 mmHg, may act as a proper death tetrad component to stratify the mortality risk of trauma patients.