Cirrhotic cardiomyopathy is independently associated with peri-transplant acute kidney injury in biliary atresia – a hepato-cardio-renal link

BACKGROUND & AIMS: Hepatorenal syndrome (HRS-AKI) confers significant morbidity and mortality in patients with cirrhosis. Cirrhotic cardiomyopathy (CCM), a prevalent co-morbidity in adults with growing recognition in children, leads to hemodynamic perturbations that may compound the maladaptive physiology resulting in HRS-AKI. We aimed to explore a hepato-cardio-renal link in in pediatric cirrhosis by examining peri-transplant AKI, with a focus on CCM and Major Adverse Kidney Events at 28 days (MAKE28) in liver transplant (LT) patients. METHODS: Single-center, retrospective study of pediatric LT for biliary atresia (BA) from 2014-2020. Peri-LT AKI was defined as AKI within 7 days of LT. CCM was defined as left ventricular mass index to height (LMVI) of ≥95 g/m2.7, and/or relative wall thickness ≥0.42. RESULTS: Of 62 BA patients (age 1.1 years [IQR 0.8-2.4]), 29% had AKI, 61% had CCM, and 40% fulfilled MAKE28. AKI patients had higher blood product and vasoactive requirements, and lower ventilator free days, compared to no-AKI patients. Median length of stay was 133 (IQR 54-121) vs. 19.5 (IQR 8.5-41) days for AKI and no AKI patients, respectively (p<0.001). CCM was more prevalent in those with peri-LT AKI (OR 6.6, CI 1.7-23, p=0.005). CCM remained significant after adjusting for age, markers liver disease severity, and intraoperative events. CONCLUSION: BA patients face high morbidity peri-LT in the setting of prevalent AKI. The association between pediatric CCM with AKI suggests cardiac dysfunction may be an independent risk factor of HRS-AKI. While studies are needed to further define the relationship between CCM and renal injury, pre-LT echocardiogram has the potential to facilitate timely identification and management of children at risk for HRS-AKI, and thereby promote renal recovery.