Hepato-Renal Syndrome Post Liver Transplantation, Bridge Therapy with Continuous Renal Replacement Therapy in Type 1A Emergency. Successful Re-Transplant: A Case Report

Introduction: Renal dysfunction after liver transplantation (LT) is common, with an incidence of 20 to 40%. Nephrotoxicity is a common cause. The presentation of sudden anuria and persistent liver dysfunction forces us to suspect different pathologies. Case Report: A 61 year old female, with liver cirrhosis (NASH) Child-Pugh C 10 and MELD 14 had a LT. Explant showed cirrhosis, steatosis 5% and Mallory bodies. 24 hrs after LT she presented cardiogenic shock, abnormal liver function test (LFT s) ; acute renal failure (ARF) with oliguria, continuous renal replacement therapy (CRRT) was started. No improvement in LFT’s was seen in 24hrs, she was reoperated for suspected outflow obstruction. A congestive, discolorating graft was found, which improved with positioning. A biopsy reported massive hepatic necrosis 85% predominantly in zones 2 and 3. State 1A emergency was reported, a successful retransplantation was performed on day +5. CRRT was suspended because of spontaneus diuresis. Liver explant confirmed 90% necrosis, intense pericentral sinusoidal congestion regarding venous obstruction. Postop evolution was uneventful and she was finally discharged on day +23 with normal liver and kidney function. Discussion and Conclusions: The continuous elevated transaminases suggests significant hepatic necrosis. Etiological reasons of early graft dysfunction after transplantation are multiple and include: ischemiareperfusion injury, primary dysfunction , technical complications , rejection and infection. It has been suggested that 5% of ARF secondary LT requires CRRT. It is recomended the use of CRRT in anuric patients and intensive resuscitation, as in our case.