The prognostic impact of cirrhosis on patients receiving maintenance haemodialysis

Abstract

Background: Further study is needed on the prognostic impact of cirrhosis on haemodialysis patients.Aim: To evaluate cirrhosis' impact according to severity on survival and to provide therapeutic guidelines for haemodialysis cirrhotic patients. Methods: Patients with end-stage renal failure treated with haemodialysis were included retrospectively from 01/01/2000 to 31/12/2004 and prospectively from 01/01/2005 to 31/12/2014 in our French Region. Clinical data, presence of cirrhosis and its severity were recorded at the beginning of haemodialysis. The primary endpoint was 2-year survival.Results: Seven thousand three hundred and fifty-four patients (96%) without cirrhosis and 304 patients (4%) with cirrhosis were included. Two-year survival in noncirrhotic patients was higher than in cirrhotic patients (71.7% vs 54.4%, P < 0.0001).Patients with decompensated cirrhosis had a worse 2-year outcome (44.1%) as compared to compensated cirrhotic (62.8%, P = 0.002) and noncirrhotic patients (71.7%, P < 0.0001). Compensated and decompensated cirrhosis were independent predictive factors of 2-year mortality. In sensitivity analysis restricted to cirrhotic patients, 2-year survival of Child-Pugh A patients was higher than in Child-Pugh B and C patients (65.5% vs 27.7% vs 0%, P < 0.0001). Development of predictive models based either on severity scores (MELD and Child-Pugh) and extrahepatic comorbidities allowed correct classification of around 70% of patients in terms of mortality and may help to better stratify mortality risk in this population. Conclusions: Cirrhosis is independently associated with mortality in haemodialysis patients. Patients with severe cirrhosis have a poor 2-year outcome. Severity of cirrhosis and presence of extrahepatic comorbidities should be considered when deciding to initiate renal replacement therapy.

Editorial: when cirrhosis deserves haemodialysis—rethinking strategies. Authors’ reply

“…Conversely, 5‐year survival of patients who underwent SLKT is around 70%–75% . We agree that specific survival data of haemodialysis patients with compensated cirrhosis classified as stage 1 (absence of portal hypertension) are still lacking in previous studies including our two recent . Despite the absence of such data, we consider that haemodialysis patients with compensated cirrhosis should be evaluated for SLKT.…”

“…We read with interest the comments of Dr Reverter on our article entitled “The prognostic impact of cirrhosis in patients receiving maintenance haemodialysis” . We agree that the decision to initiate haemodialysis in patients with decompensated cirrhosis should be weighted according to anticipation of their low survival and therefore mainly reserved for those with a possibility of improvement of liver function or to candidates for simultaneous liver‐kidney transplantation (SLKT).…”

Prevalence and outcomes of chronic liver disease in patients receiving dialysis: systematic review and meta-analysis

“…Baseline study characteristics are outlined in Table 1 . Six studies were performed in East Asia [ 15 , 16 , 20–22 , 28 ], five in Europe [ 14 , 17 , 19 , 25 , 26 ], two in the USA [ 18 , 24 ] and one in North Africa [ 27 ]. One study was multinational [ 23 ].…”

“…Discrepancies were resolved through discussion with members of the study team (S.S. and K.F.). A total of 15 studies met the inclusion criteria and were used in the analysis [ 14–28 ] (see Figure 1 ). Detailed reasons for exclusion were noted.…”

Editorial: when cirrhosis deserves haemodialysis—rethinking strategies

“…The decision to initiate maintenance haemodialysis (MHD) in patients with cirrhosis and end‐stage renal disease remains a challenging decision which balances objective, subjective and intangible considerations regarding the real offered benefit. In a recent issue of Alimentary Pharmacology & Therapeutics, Artru et al analyse the 2‐year outcomes in a large cohort of patients receiving MHD specially focusing on patients with cirrhosis and its prognostic impact . Although only 4% of the cohort had cirrhosis, it was a strong prognostic factor with higher relative weight than cardiovascular issues (cardiac failure, infarction, stroke), diabetes and even neoplasia if only considering decompensated patients.…”