Digestive Diseases and Sciences

, Volume 61, Issue 1, pp 309–316 | Cite as

Prevalence, Severity, and Impact of Renal Dysfunction in Acute Liver Failure on the US Liver Transplant Waiting List

  • Nathalie H. Urrunaga
  • Laurence S. Magder
  • Matthew R. Weir
  • Don C. Rockey
  • Ayse L. Mindikoglu
Original Article


Background and Aims

Although renal dysfunction is a known complication of acute liver failure (ALF), its frequency, severity, and impact among patients with ALF on the US liver transplant list are not well defined.


Organ Procurement and Transplantation data for ALF patients listed as status 1/1A from 2002 to 2012 were analyzed. The frequency and severity of renal dysfunction at the time of listing [the latter was categorized in 5 stages using estimated GFR (eGFR) according to Chronic Kidney Disease Epidemiology Collaboration creatinine 2009 equation] were determined and the association between renal dysfunction and waiting list mortality was assessed using Cox proportional hazard regression analysis.


There were a total of 2280 adult patients with ALF, including 56 % with renal dysfunction (defined as eGFR < 60 ml/min/1.73 m2) at listing. The highest proportion of patients with renal dysfunction was among those with ALF caused by hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, fatty liver disease of pregnancy, heat stroke/hyperthermia, hepatitis A virus, and drug-induced liver injury due to acetaminophen APAP, phenytoin, trimethoprim-sulfamethoxazole, and macrolides. Despite the fact that 69 % (468/674) of patients with APAP-induced ALF listed as status 1/1A had renal dysfunction, only 0.9 % underwent simultaneous liver-kidney transplantation. Six-week survival probabilities in patients with ALF on the liver transplant waiting list were 71, 59, 56, 59, and 42 % with renal dysfunction stages of 1, 2, 3, 4, and 5, respectively. Multivariate analysis showed that after controlling for age, etiology of ALF, INR, total bilirubin, and region, the relative risk of death increased progressively as eGFR declined (P < 0.0001).


Among patients with ALF on the liver transplant waiting list, renal dysfunction was common (overall prevalence of 56 %). Most importantly, severe renal dysfunction was associated with significantly increased mortality.


Renal dysfunction Acute liver failure Liver transplantation CKD-EPI OPTN 



Acute liver failure


Organ Procurement and Transplantation Network


United network for organ sharing


International normalized ratio


Model for end-stage liver disease



This work was supported in part by Health Resources and Services Administration contract 234-2005-370011C. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government. We thank Jean-Pierre Raufman, M.D. (Professor of Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine) for reviewing our manuscript.


Nathalie H. Urrunaga M.D., M.S., designed and performed the study, analyzed the data, and wrote the paper. Laurence S. Magder Ph.D., M.P.H., analyzed the data and contributed with important suggestions. Matthew R. Weir, M.D., contributed with important suggestions. Don C. Rockey, M.D., wrote the paper and contributed with important suggestions. Ayse L. Mindikoglu M.D., M.P.H., designed and performed the study, analyzed the data, and wrote the paper.


The project described was supported by Grant Number 5 K23 DK089008-05 from the National Institutes of Health (NIH), National Institute of Diabetes and Digestive and Kidney Diseases (to Ayse L. Mindikoglu, M.D., M.P.H.), and its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institute of Diabetes and Digestive and Kidney Diseases or the NIH.” “Nathalie H. Urrunaga, M.D., M.S., was supported by Grant Number 5 T32 DK067872-10 from the National Institutes of Health (NIH), National Institute of Diabetes and Digestive and Kidney Diseases.

Compliance with ethical standards

Conflict of interest

None to declare.

Meeting material

Urrunaga N, Mindikoglu AL. Prevalence, Severity, and Impact of Renal Dysfunction in Acute Liver Failure on the US Liver Transplant Waiting List. Gastroenterology 2014, 146, Issue 5, S-915. Abstract was presented on May 4, 2014, at Digestive Disease Week (DDW), Chicago, IL.


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Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Nathalie H. Urrunaga
    • 1
  • Laurence S. Magder
    • 2
  • Matthew R. Weir
    • 3
  • Don C. Rockey
    • 4
  • Ayse L. Mindikoglu
    • 1
  1. 1.Division of Gastroenterology and Hepatology, Department of MedicineUniversity of Maryland School of MedicineBaltimoreUSA
  2. 2.Division of Biostatistics and Bioinformatics, Department of Epidemiology and Public HealthUniversity of Maryland School of MedicineBaltimoreUSA
  3. 3.Division of Nephrology, Department of MedicineUniversity of Maryland School of MedicineBaltimoreUSA
  4. 4.Department of MedicineMedical University of South CarolinaCharlestonUSA

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