Renal Recovery and Mortality Risk Among Patients with Hepatorenal Syndrome Receiving Chronic Maintenance Dialysis

Background: Kidney replacement therapy is controversial for patients with hepatorenal syndrome who may not be liver transplant candidates. Data surrounding the likelihood of recovery of kidney function and mortality following outpatient dialysis initiation in patients with dialysis-requiring hepatorenal syndrome could inform discussions between patients and providers. Methods: We performed a retrospective cohort study of patients with hepatorenal syndrome who were registered in the United States Renal Data System between 1996-2015 (n=7,830) as receiving maintenance dialysis. We characterized patients with hepatorenal syndrome by recovery of kidney function using Fine-Gray models. We also examined hazard of recovery of kidney function and death among those with hepatorenal syndrome versus those with acute tubular necrosis (n=48,861) using adjusted Fine-Gray and Cox models, respectively. Results: 11% of patients with hepatorenal syndrome recovered kidney function. Those with higher likelihood of recovery were younger, non-Hispanic White, and had a history of alcohol use. Compared to patients with acute tubular necrosis, patients with hepatorenal syndrome as the attributed cause of kidney disease had a lower hazard of recovery (HR 0.22; 95% CI 0.21-0.24) and higher hazard of death within one year (HR 3.10; 95% CI 2.99-3.23) in fully adjusted models. Conclusions: Patients with hepatorenal syndrome receiving chronic maintenance dialysis had a lower likelihood of recovery of kidney function and higher mortality risk compared to patients with acute tubular necrosis. Among patients with hepatorenal syndrome, those most likely to recover kidney function were younger, had a history of alcohol use, and lacked co-morbid conditions. These data may inform prognosis and discussions surrounding treatment options when patients with HRS need chronic maintenance dialysis therapy.