Protective value of ischemia-free liver transplantation on post-transplant acute kidney injury

Background & Aims: Ischemia-free liver transplantation (IFLT) completely avoids ischemia–reperfusion injury (IRI), thus potentially reducing acute kidney injury (AKI) after liver transplantation (LT). Therefore, this study investigated whether IFLT has a protective effect against AKI after LT. Methods: In total, 862 patients who had undergone LT between 2017 to 2022 were divided into an ischemia-free liver transplantation group (IFLT group) and conventional liver transplantation group (CLT group) based on the surgical methods used. Propensity score matching (PSM) was used for post hoc randomization in the 1:1 matching between the groups. Post-transplant kidney function, graft function, and patient survival were compared between the groups. Multivariate logistic regression analysis was used to identify the risk factors of AKI after LT. Results: Overall, 745 out of 862 patients were finally enrolled, of whom 98 underwent IFLT. PSM created 94 pairs of patients. IFLT resulted in a significant reduction in Stage-3 AKI (3.2% vs. 16.0%, p = 0.003), severe AKI (SAKI) (13.8% vs. 25.5%, p = 0.044), and renal replacement therapy (RRT) ratio (3.2% vs. 12.8%, p = 0.015) compared with the CLT group. The early allograft dysfunction (EAD) incidence of the IFLT group significantly decreased (8.5% vs. 44.7%, p <0.001). Livers from the extended criteria donation (ECD) were received in 49 patients who underwent IFLT and 46 patients who underwent CLT. Compared with the ECD-CLT group, the Stage-3 AKI and SAKI incidence in the ECD-IFLT group were both decreased (p <0.05). Multivariate logistic regression analysis further confirmed that both using IFLT and avoiding ECD were protective factors for post-transplant Stage-3 AKI. Conclusions: IFLT significantly reduces the incidence of post-transplant SCKI, Stage-3 AKI, and RRT. Importantly, this protective effect is also present in patients receiving ECD livers. Impact and implications: Ischemia-free liver transplantation significantly reduces the incidence of severe acute kidney injury, Stage-3 acute kidney injury and renal replacement therapy after liver transplantation. Importantly, this protective effect is also present in patients receiving extended criteria donation livers. Clinical trial number: ChiCTR2400081755.