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Pelusio C, Endres P, Neyra JA, Allegretti AS. Renal Replacement Therapy in Cirrhosis: A Contemporary Review. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:133-138. [PMID: 38649217 PMCID: PMC11103613 DOI: 10.1053/j.akdh.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/20/2023] [Accepted: 01/02/2024] [Indexed: 04/25/2024]
Abstract
Acute kidney injury is a common complication of decompensated cirrhosis, frequently requires hospitalization, and carries a high short-term mortality. This population experiences several characteristic types of acute kidney injury: hypovolemic-mediated (prerenal), ischemic/nephrotoxic-mediated (acute-tubular necrosis), and hepatorenal syndrome. Prerenal acute kidney injury is treated with volume resuscitation. Acute-tubular necrosis is treated by optimizing perfusion pressure and discontinuing the offending agent. Hepatorenal syndrome, a unique physiology of decreased effective arterial circulation leading to renal vasoconstriction and ultimately acute kidney injury, is treated with plasma expansion with albumin and splanchnic vasoconstrictors such as terlipressin or norepinephrine. Common acute stressors such as bleeding, infection, and volume depletion often contribute to multifactorial acute kidney injury. Even with optimal medical management, many clinicians are faced with the challenge of initiating renal replacement therapy in these patients. This article reviews the epidemiology, indications, and complex considerations of renal replacement therapy for acute kidney injury in decompensated cirrhosis.
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Affiliation(s)
- Caterina Pelusio
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy; Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Paul Endres
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA.
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2
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Griffin C, Asrani SK, Regner KR. Update on Assessment of Estimated Glomerular Filtration Rate in Patients With Cirrhosis. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:307-314. [PMID: 37389536 DOI: 10.1053/j.akdh.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 07/01/2023]
Abstract
Kidney disease is associated with adverse outcomes in patients with cirrhosis including increased post-liver transplantation (LT) mortality. Therefore, diagnosis and staging of kidney disease are critical to timely implementation of treatment and have important implications for transplant eligibility. Serum creatinine (sCr) is a key component of the Model for End-Stage Liver Disease score in LT candidates, and sCr-based estimated glomerular filtration rate (eGFR) values play an important role in determining medical urgency for LT. However, the use of sCr to assess kidney function may be limited in the cirrhotic milieu due to decreased creatinine production, interference of bilirubin with some laboratory assays for sCr, and expansion of the volume of distribution of creatinine. Therefore, conventional eGFR equations perform poorly in patients with cirrhosis and may overestimate kidney function leading to delayed diagnosis of acute kidney injury or lower priority for LT in patients with a truly low glomerular filtration rate. In this review, we will provide an update on the use of sCr for diagnosis and staging of kidney disease in patients with cirrhosis, discuss the limitations of sCr-based eGFR equations, and discuss novel eGFR equations that have been developed in patients with cirrhosis.
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Affiliation(s)
- Connor Griffin
- Division of Hepatology, Baylor University Medical Center, Dallas, TX
| | - Sumeet K Asrani
- Division of Hepatology, Baylor University Medical Center, Dallas, TX
| | - Kevin R Regner
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI.
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3
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Cooper KM, Colletta A, Moulton K, Ralto KM, Devuni D. Kidney disease in patients with chronic liver disease: Does sex matter? World J Clin Cases 2023; 11:3980-3992. [PMID: 37388789 PMCID: PMC10303604 DOI: 10.12998/wjcc.v11.i17.3980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/30/2023] [Accepted: 05/16/2023] [Indexed: 06/12/2023] Open
Abstract
Kidney disease in patients with liver disease is serious and increases mortality. Up to 50% of patients hospitalized experience an episode of acute kidney injury. In general, men with liver disease are thought to be at increased risk of kidney disease. However, this association should be considered with caution because most studies use creatinine-based inclusion criteria, which is negatively biased against women. In this review, we synthesize data on sex differences in kidney disease in patients with chronic liver disease in the clinical setting and discuss potential physiologic underpinnings.
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Affiliation(s)
- Katherine M Cooper
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Alessandro Colletta
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Kristen Moulton
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Kenneth M Ralto
- Department of Medicine, Division of Renal Medicine, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Deepika Devuni
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01665, United States
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Singal AK, Kuo YF, Reddy KR, Bataller R, Kwo P. Healthcare burden and outcomes of hepatorenal syndrome among cirrhosis-related hospitalisations in the US. Aliment Pharmacol Ther 2022; 56:1486-1496. [PMID: 36196562 DOI: 10.1111/apt.17232] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/07/2022] [Accepted: 09/11/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Hepatorenal syndrome (HRS) contributes to significant morbidity and mortality in hospitalised patients with cirrhosis. AIMS To examine recent trends, magnitude and outcomes of HRS in the National Inpatient Sample (NIS) database METHODS: Among the NIS database on cirrhosis hospitalisations (2016-2019) due to alcohol (ALD), chronic viral hepatitis (CVH), or NASH and complicated by acute kidney injury (AKI) were analyzed. RESULTS Of 113,454 hospitalisations, 18,735 (16.5%) had HRS (mean age 56 years, 36% females, 68% whites, 80% ALD, 7% NASH) with a stable trend over time. Among 1:1 propensity-matched 36,090 hospitalisations, the odds of HRS were 12% higher in NASH versus CVH. Based on weighted national estimates, there were 27,180 (8.3 per 100,000 US population) HRS hospitalisations in 2019, with economic burden of $4.2 billion USD. Mean hospitalisation and total charges (ALD vs. CVH vs. NASH) were 11 versus 10.8 versus 9.2 days and 151,000 versus 157,000 versus 120,000 USD, respectively; p < 0.001. In-hospital mortality was 18.9%, higher in HRS (25.8 vs. 12%, p < 0.001), and decreased by 15% annually. Survivors were more likely to be discharged to short- or long-term care facilities (HRS vs. non-HRS [42 vs. 27%, p < 0.001]); only 28.7% received palliative care. CONCLUSION HRS was the cause of AKI in 16.5% of patients hospitalised with cirrhosis and conferred significant healthcare burden with 27,180 HRS hospitalisations in 2019 and requiring an estimated 4.2 billion USD for hospital care. While there has been a decrease in in-hospital mortality over time, it remained high at 23.7% in 2019 in those with HRS.
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Affiliation(s)
- Ashwani K Singal
- Department of Medicine, University of SD Sanford School of Medicine, Sioux Falls, South Dakota, USA.,Division of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, South Dakota, USA
| | - Yong-Fang Kuo
- Department of Biostatistics, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramon Bataller
- Division of Gastroenterology and Hepatology, UPMC, Pittsburgh, Philadelphia, USA
| | - Paul Kwo
- Division of Gastroenterology and Hepatology, Stanford University Medical School, Stanford, California, USA
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Del Risco-Zevallos J, Andújar AM, Piñeiro G, Reverter E, Toapanta ND, Sanz M, Blasco M, Fernández J, Poch E. Management of acute renal replacement therapy in critically ill cirrhotic patients. Clin Kidney J 2022; 15:1060-1070. [PMID: 35664279 PMCID: PMC9155212 DOI: 10.1093/ckj/sfac025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Indexed: 02/07/2023] Open
Abstract
Renal replacement therapy (RRT) in cirrhotic patients encompasses a number of issues related to the particular characteristics of this population, especially in the intensive care unit (ICU) setting. The short-term prognosis of cirrhotic patients with acute kidney injury is poor, with a mortality rate higher than 65% in patients with RRT requirement, raising questions about the futility of its initiation. Regarding the management of the RRT itself, there is still no consensus with respect to the modality (continuous versus intermittent) or the anticoagulation required to improve the circuit life, which is shorter than similar at-risk populations, despite the altered haemostasis in traditional coagulation tests frequently found in these patients. Furthermore, volume management is one of the most complex issues in this cohort, where tools used for ambulatory dialysis have not yet been successfully reproducible in the ICU setting. This review attempts to shed light on the management of acute RRT in the critically ill cirrhotic population based on the current evidence and the newly available tools. We will discuss the timing of RRT initiation and cessation, the modality, anticoagulation and fluid management, as well as the outcomes of the RRT in this population, and provide a brief review of the albumin extracorporeal dialysis from the point of view of a nephrologist.
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Affiliation(s)
| | | | - Gastón Piñeiro
- Nephrology and Renal Transplantation Department, Hospital Clínic de Barcelona. University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Enric Reverter
- Liver and Digestive ICU, Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Néstor David Toapanta
- Liver and Digestive ICU, Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Miquel Sanz
- Liver and Digestive ICU, Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Miquel Blasco
- Nephrology and Renal Transplantation Department, Hospital Clínic de Barcelona. University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Javier Fernández
- Liver and Digestive ICU, Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
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Wang PL, Silver SA, Djerboua M, Thanabalasingam S, Zarnke S, Flemming JA. Recovery From Acute Kidney Injury Requiring Dialysis in Patients With Cirrhosis: A Population-Based Study. Am J Kidney Dis 2021; 80:55-64.e1. [PMID: 34808296 DOI: 10.1053/j.ajkd.2021.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/21/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE The decision to initiate kidney replacement therapy (KRT) for acute kidney injury (AKI) in cirrhosis remains controversial as it is unclear which patients will benefit. We sought to characterize factors associated with recovery from AKI requiring KRT in patients with cirrhosis to inform shared clinical decision-making. STUDY DESIGN Population-based retrospective cohort study. SETTING & PARTICIPANTS Adult patients from Ontario, Canada identified, using administrative data, to have cirrhosis at the time of admission to hospital with AKI (based on serum creatinine) requiring KRT (01/01/2009-12/31/2016) and followed until 12/31/2017. EXPOSURES Demographics and comorbidities prior to admission. OUTCOMES Kidney recovery defined as the absence of KRT for at least 30 days. ANALYTICAL APPROACH The cumulative incidences of kidney recovery, death, and liver transplantation were calculated at 1, 3, 6, and 12 months and independent predictors of kidney recovery were evaluated using Fine and Gray competing risk regression models that generated subdistribution hazards ratios (sHR). RESULTS Overall, 722 patients were included (median age 61 years [IQR 54-68]; MELD-Na 26 [IQR 22-34]; 66% male; 52% had viral hepatitis, 25% non-alcoholic fatty liver disease, 18% alcohol-associated liver disease). The cumulative incidences of kidney recovery at 1, 3, 6, and 12 months were 3%, 22%, 25%, and 26%, respectively. Higher MELD-Na score (sHR 0.72 per 5 units, 95%CI 0.65-0.80), acute-on-chronic liver failure (sHR 0.61, 95%CI 0.43-0.86), and sepsis (sHR 0.57, 95%CI 0.41-0.81) were associated with a lower hazard of kidney recovery while those on a liver transplant waitlist (sHR 3.10, 95% CI 1.96-4.88) and who were admitted to a teaching hospital (sHR 1.48, 95%CI 1.05-2.08) were more likely to experience kidney recovery. LIMITATIONS Observational design, AKI etiology not identified. CONCLUSIONS Kidney recovery from KRT occurred in only one-quarter of patients and was very unlikely after 3-months. These findings provide information regarding prognosis that may guide decisions regarding KRT initiation and continuation.
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Affiliation(s)
| | | | | | | | | | - Jennifer A Flemming
- Department of Medicine; ICES, Queen's University; Department of Public Health Sciences, Queen's University.
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Yang Y, Ge B, Liu Y, Feng J. The efficacy of biomarkers in the diagnosis of acute kidney injury secondary to liver cirrhosis. Medicine (Baltimore) 2021; 100:e25411. [PMID: 33832138 PMCID: PMC8036071 DOI: 10.1097/md.0000000000025411] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT This study is to investigate the role of neutrophil gelatinase-associated lipocalin (NGAL), cystatin C (CysC) and creatinine in the diagnosis of acute kidney injury (AKI) secondary to liver cirrhosis.A total of 825 patients (including 540 liver cirrhosis patients and 285 healthy controls) were enrolled. Liver cirrhosis patients were further subdivided into AKI secondary to liver cirrhosis group (AKI group, 210 patients) and simple liver cirrhosis group (LC group, 330 patients). Serum NGAL/urine NGAL (sNGAL/uNGAL), and serum creatinine (sCr) levels as well as estimated glomerular filtration rates were measured. The diagnostic performances of these indicators in AKI secondary to liver cirrhosis were evaluated.The levels of sNGAL, uNGAL, CysC and sCr in the AKI group were significantly higher than those of LC and healthy control groups. However, the eGFR and c-aGFR of AKI group were significantly lower. With the progression of AKI (AKI-S1→AKI-S2→AKI-S3), the levels of sNGAL, uNGAL, CysC and sCr increased gradually, while the levels of c-aGFR and eGFR decreased gradually. The sNGAL, uNGAL and CysC were positively correlated with sCr (r = 0.638, 0.635, and 0.650), but negatively correlated with c-aGFR (r = -0.617, -0.606 and -0.655). However, eGFR had a negative correlation with sCr (r = -0.711), but a positive correlation with c-aGFR (r = 0.736). ROC curve analysis showed that the area under the curve for uNGAL was the largest (0.976), followed by sNGAL (0.967). The diagnostic efficacy of uNGAL and sNGAL in AKI group were 0.907 and 0.870, and the risk degrees were OR = 54.524 and 5.115, respectively.NGAL might perform better than sCr and CysC in the diagnosis of AKI secondary to liver cirrhosis, while uNGAL might be a better indicator than sNGAL in AKI diagnosis.
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Affiliation(s)
- Yuwei Yang
- Department of Laboratory Medicine, Mianyang Central Hospital, Affiliated to Southwest Medical University, Mianyang
| | - Bin Ge
- Department of Laboratory Medicine, Pidu District People's Hospital, Chengdu, Sichuan, China
| | - Yan Liu
- Department of Laboratory Medicine, Pidu District People's Hospital, Chengdu, Sichuan, China
| | - Jiafu Feng
- Department of Laboratory Medicine, Mianyang Central Hospital, Affiliated to Southwest Medical University, Mianyang
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Lunyera J, Clare RM, Chiswell K, Scialla JJ, Pun PH, Thomas KL, Starks MA, Diamantidis CJ. Racial Differences in AKI Incidence Following Percutaneous Coronary Intervention. J Am Soc Nephrol 2021; 32:654-662. [PMID: 33443096 PMCID: PMC7920184 DOI: 10.1681/asn.2020040502] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 10/31/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Undergoing percutaneous coronary intervention (PCI) is a risk factor for AKI development, but few studies have quantified racial differences in AKI incidence after this procedure. METHODS We examined the association of self-reported race (Black, White, or other) and baseline eGFR with AKI incidence among patients who underwent PCI at Duke University Medical Center between January 1, 2003, and December 31, 2013. We defined AKI as a 0.3 mg/dl absolute increase in serum creatinine within 48 hours, or ≥1.5-fold relative elevation within 7 days post-PCI from the reference value ascertained within 30 days before PCI. RESULTS Of 9422 patients in the analytic cohort (median age 63 years; 33% female; 75% White, 20% Black, 5% other race), 9% developed AKI overall (14% of Black, 8% of White, 10% of others). After adjustment for demographics, socioeconomic status, comorbidities, predisposing medications, PCI indication, periprocedural AKI prophylaxis, and PCI procedural characteristics, Black race was associated with increased odds for incident AKI compared with White race (odds ratio [OR], 1.79; 95% confidence interval [95% CI], 1.48 to 2.15). Compared with Whites, odds for incident AKI were not significantly higher in other patients (OR, 1.30; 95% CI, 0.93 to 1.83). Low baseline eGFR was associated with graded, higher odds of AKI incidence (P value for trend <0.001); however, there was no interaction between race and baseline eGFR on odds for incident AKI (P value for interaction = 0.75). CONCLUSIONS Black patients had greater odds of developing AKI after PCI compared with White patients. Future investigations should identify factors, including multiple domains of social determinants, that predispose Black individuals to disparate AKI risk after PCI.
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Affiliation(s)
- Joseph Lunyera
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Robert M. Clare
- Duke Clinical Research Institute, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Julia J. Scialla
- Departments of Medicine and Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Patrick H. Pun
- Duke Clinical Research Institute, Department of Medicine, Duke University School of Medicine, Durham, North Carolina,Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Kevin L. Thomas
- Duke Clinical Research Institute, Department of Medicine, Duke University School of Medicine, Durham, North Carolina,Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Monique A. Starks
- Duke Clinical Research Institute, Department of Medicine, Duke University School of Medicine, Durham, North Carolina,Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Clarissa J. Diamantidis
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina,Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Regner KR. Patients with Hepatorenal Syndrome Should Be Dialyzed? COMMENTARY. KIDNEY360 2020; 2:413-414. [PMID: 35378024 PMCID: PMC8786001 DOI: 10.34067/kid.0006862020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/07/2020] [Indexed: 02/04/2023]
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Wadei HM. Patients with Hepatorenal Syndrome Should Be Dialyzed? CON. KIDNEY360 2020; 2:410-412. [PMID: 35369028 PMCID: PMC8785992 DOI: 10.34067/kid.0006872020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/08/2020] [Indexed: 02/04/2023]
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Changing epidemiology and outcomes of acute kidney injury in hospitalized patients with cirrhosis - a US population-based study. J Hepatol 2020; 73:1092-1099. [PMID: 32387698 PMCID: PMC7994029 DOI: 10.1016/j.jhep.2020.04.043] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/09/2020] [Accepted: 04/27/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Acute kidney injury (AKI) is a significant clinical event in cirrhosis yet contemporary population-based studies on the impact of AKI on hospitalized cirrhotics are lacking. We aimed to characterize longitudinal trends in incidence, healthcare burden and outcomes of hospitalized cirrhotics with and without AKI using a nationally representative dataset. METHODS Using the 2004-2016 National Inpatient Sample (NIS), admissions for cirrhosis with and without AKI were identified using ICD-9 and ICD-10 codes. Regression analysis was used to analyze the trends in hospitalizations, costs, length of stay and inpatient mortality. Descriptive statistics, simple and multivariable logistic regression were used to assess associations between individual characteristics, comorbidities, and cirrhosis complications with AKI and death. RESULTS In over 3.6 million admissions for cirrhosis, 22% had AKI. AKI admissions were more costly (median $13,127 [IQR $7,367-$24,891] vs. $8,079 [IQR $4,956-$13,693]) and longer (median 6 [IQR 3-11] days vs. 4 [IQR 2-7] days). Over time, AKI prevalence doubled from 15% in 2004 to 30% in 2016. CKD was independently and strongly associated with AKI (adjusted odds ratio 3.75; 95% CI 3.72-3.77). Importantly, AKI admissions were 3.75 times more likely to result in death (adjusted odds ratio 3.75; 95% CI 3.71-3.79) and presence of AKI increased risk of mortality in key subgroups of cirrhosis, such as those with infections and portal hypertension-related complications. CONCLUSIONS The prevalence of AKI is significantly increased among hospitalized cirrhotics. AKI substantially increases the healthcare burden associated with cirrhosis. Despite advances in cirrhosis care, a significant gap remains in outcomes between cirrhotics with and without AKI, suggesting that AKI continues to represent a major clinical challenge. LAY SUMMARY Sudden damage to the kidneys is becoming more common in people who are hospitalized and have cirrhosis. Despite advances in cirrhosis care, those with damage to the kidneys remain at higher risk of dying.
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Vaz NF, da Cunha VNR, Cunha-Silva M, Sevá-Pereira T, de Souza Almeida JR, Mazo DF. Evolution of diagnostic criteria for acute kidney injury in patients with decompensated cirrhosis: A prospective study in a tertiary university hospital. Clin Res Hepatol Gastroenterol 2020; 44:551-563. [PMID: 31427198 DOI: 10.1016/j.clinre.2019.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 06/22/2019] [Accepted: 07/19/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recently, changes in acute kidney injury (AKI) diagnostic criteria have been proposed (ICA-AKI criteria). However, in Brazil there is a paucity of data and analyses that evaluate AKI in patients with cirrhosis and determine the impact of the implemented AKI criteria changes. Therefore, this study sought to evaluate the incidence of AKI in patients with cirrhosis; to evaluate the agreement between traditional and ICA-AKI criteria; and to assess its clinical and laboratory characteristics, etiologies, risk factors and outcomes. METHODS This is a prospective cohort study in hospitalized patients with cirrhosis and acute decompensation. The total number of hospitalizations was evaluated using the PWP statistical model for recurring events; P values<0.05 were considered significant. RESULTS A total of 154 admissions of 75 patients were included in the study. Among the hospitalizations, 89 (57.79%) met the ICA-AKI criteria. There was substantial agreement between both AKI classifications (Kappa 0.7293). The main etiology of AKI was pre-renal (59.55%), followed by renal (26.96%) and hepatorenal syndrome (10.11%). A multivariate analysis uncovered risk factors for ICA-AKI, including the MELD score (P=0.0162, RR:1.055, 95% CI:1.010-1.101) and the use of furosemide (P=0.001,RR:2.360, 95% CI:1.417-3.931). A univariate analysis found an association between in-hospital mortality and serum creatinine (sCr)≥1.5mg/dL(P=0.0373), MELD (P=0.0296), bilirubin (P=0.0064), and infection (P=0.0045), while in the multivariate analysis, the bilirubin levels (P=0.0030, RR:1.077, 95% CI: 1.025-1.130) and the presence of shock (P=0.0002, RR:8.511, 95% CI: 2.746-26.377) were associated with in-hospital mortality. Among the hospitalizations with AKI, death was significantly associated with non-response to treatment and dialysis. Initial stage 1A-AKI had lower in-hospital mortality than stage 1B-AKI. CONCLUSIONS AKI incidence was high in this cohort of patients with decompensated cirrhosis, and substantial agreement between AKI definitions was observed. In-hospital mortality was associated with worse liver function, AKI, infection and the presence of shock. Also, sCr>1,5mg/dL remained an important prognostic factor.
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Affiliation(s)
- Nayana Fonseca Vaz
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (UNICAMP), Rua Carlos Chagas n°420, 13083-878 Campinas, Brazil
| | - Vanessa Nogueira Rodrigues da Cunha
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (UNICAMP), Rua Carlos Chagas n°420, 13083-878 Campinas, Brazil
| | - Marlone Cunha-Silva
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (UNICAMP), Rua Carlos Chagas n°420, 13083-878 Campinas, Brazil
| | - Tiago Sevá-Pereira
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (UNICAMP), Rua Carlos Chagas n°420, 13083-878 Campinas, Brazil
| | - Jazon Romilson de Souza Almeida
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (UNICAMP), Rua Carlos Chagas n°420, 13083-878 Campinas, Brazil
| | - Daniel F Mazo
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (UNICAMP), Rua Carlos Chagas n°420, 13083-878 Campinas, Brazil; Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar n°255, Instituto Central, 9159 Sao Paulo, Brazil.
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Trends of Acute Kidney Injury Requiring Dialysis Among Hospitalized Patients Undergoing Invasive Electrophysiology Procedures. Crit Pathw Cardiol 2020; 19:98-103. [PMID: 32404641 DOI: 10.1097/hpc.0000000000000214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Electrophysiology (EP) procedures carry the risk of kidney injury due to contrast/hemodynamic fluctuations. We aim to evaluate the national epidemiology of acute kidney injury requiring dialysis (AKI-D) in patients undergoing EP procedures. Using the National Inpatient Sample, we included 2,747,605 adult hospitalizations undergoing invasive diagnostic EP procedures, ablation and implantable device placement from 2006 to 2014. We examined the temporal trend of AKI-D and outcomes associated with AKI-D. The rate of AKI-D increased significantly in both diagnostic/ablation group (8-21/10,000 hospitalizations from 2006 to 2014, P = 0.02) and implanted device group (19-44/10,000 hospitalizations from 2006 to 2014, P < 0.01), but it was explained by temporal changes in demographics and comorbidities. Cardiac resynchronization therapy and pacemaker placement had higher risk of AKI-D compared to implantable cardioverter-defibrillator placement (23 vs. 31 vs. 14/10,000 hospitalizations in cardiac resynchronization therapy, pacemaker placement, and implantable cardioverter-defibrillator group, respectively). Development of AKI-D was associated with significant increase in in-hospital mortality (adjusted odds ratio, 9.6 in diagnostic/ablation group, P < 0.01; adjusted odds ratio, 5.1 in device implantation group, P < 0.01) and with longer length of stay (22.5 vs. 4.5 days in diagnostic/ablation group, 21.1 vs. 5.7 days in implanted device group) and higher cost (282,775 vs. 94,076 USD in diagnostic/ablation group, 295,660 vs. 102,007 USD in implanted device group). The incidence of AKI-D after EP procedures increased over time but largely explained by the change of demographics and comorbidities. This increasing trend, however, was associated with significant increase in resource utilization and in-hospital mortality in these patients.
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National trends of endoscopic retrograde cholangiopancreatography utilization and outcomes in decompensated cirrhosis. Surg Endosc 2019; 33:169-178. [PMID: 29943059 DOI: 10.1007/s00464-018-6290-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 06/18/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) can be challenging in patients with decompensated cirrhosis (DC) due to increased risk of adverse events related to liver dysfunction. Limited data exist regarding its national utilization in patients with DC. We aim to determine the trends in utilization and outcomes of ERCP among patients with DC in US hospitalizations. METHODS We identified hospitalizations undergoing ERCP (diagnostic and therapeutic) between 2000 and 2013 from the National Inpatient Sample (NIS) database and used validated ICD9-CM codes to identify DC hospitalizations. We utilized Cochrane-Armitage test to identify changes in trends and multivariable survey regression modeling for adjusted odds ratios (aOR) for adverse outcomes and mortality predictors. RESULTS There were 43782 cases of ERCPs performed in DC patients during the study period. Absolute number of ERCPs performed in this population from 2000 to 2013 showed an upward trend; however, the proportion of DC patients undergoing ERCP remained stable. We noted significant decrease in utilization of diagnostic ERCP and an increase of therapeutic ERCPs (P < 0.01). There was a significant decrease in the mean length of stay for DC patients undergoing ERCP from 8.2 days in 2000 to 7.2 days in 2013 (P < 0.01) with an increase in the mean cost of hospitalization from $17053 to $19825 (P < 0.001). Mortality rates showed a downward trend from 2000 to 2013 from 13.6 to 9.6% (P < 0.01). Increasing age, Hispanic race, diagnosis of hypertension and diabetes mellitus, and private insurance were related to adverse discharges(P < 0.01). Increasing age, presence of hepatic encephalopathy, and sepsis were associated with higher mortality (P < 0.01). CONCLUSIONS There is an increasing trend in therapeutic ERCP utilization in DC hospitalizations nationally. There is an overall decrease in mortality in DC hospitalizations undergoing ERCP. This improvement in mortality suggests improvement in both procedural technique and peri-procedural care as well as overall decreasing mortality in cirrhosis.
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Neugarten J, Golestaneh L. Female sex reduces the risk of hospital-associated acute kidney injury: a meta-analysis. BMC Nephrol 2018; 19:314. [PMID: 30409132 PMCID: PMC6225636 DOI: 10.1186/s12882-018-1122-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 10/25/2018] [Indexed: 02/07/2023] Open
Abstract
Background Female sex has been included as a risk factor in models developed to predict the development of AKI. In addition, the commentary to the Kidney Disease Improving Global Outcomes Clinical Practice Guideline for AKI concludes that female sex is a risk factor for hospital-acquired AKI. In contrast, a protective effect of female sex has been demonstrated in animal models of ischemic AKI. Methods To further explore this issue, we performed a meta-analysis of AKI studies published between January, 1978 and April, 2018 and identified 83 studies reporting sex-stratified data on the incidence of hospital-associated AKI among nearly 240,000,000 patients. Results Twenty-eight studies (6,758,124 patients) utilized multivariate analysis to assess risk factors for hospital-associated AKI and provided sex-stratified ORs. Meta-analysis of this cohort showed that the risk of developing hospital-associated AKI was significantly greater in men than in women (OR 1.23 (1.11,1.36). Since AKI is not a single disease but instead represents a heterogeneous group of disorders characterized by an acute reduction in renal function, we performed subgroup meta-analyses. The association of male sex with AKI was strongest among studies of patients who underwent non-cardiac surgery. Male sex was also associated with AKI in studies which included unselected hospitalized patients and in studies of critically ill patients who received care in an intensive care unit. In contrast, cardiac surgery-associated AKI and radiocontrast-induced AKI showed no sexual dimorphism. Conclusions Our meta-analysis contradicts the established belief that female sex confers a greater risk of AKI and instead suggests a protective role.
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Affiliation(s)
- Joel Neugarten
- Department of Medicine, Nephrology Division, Montefiore Medical Center, Albert Einstein College of Medicine, 111 E. 210 St, Bronx, NY, 10467, USA.
| | - Ladan Golestaneh
- Department of Medicine, Nephrology Division, Montefiore Medical Center, Albert Einstein College of Medicine, 111 E. 210 St, Bronx, NY, 10467, USA.
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Allegretti AS, Parada XV, Eneanya ND, Gilligan H, Xu D, Zhao S, Dienstag JL, Chung RT, Thadhani RI. Prognosis of Patients with Cirrhosis and AKI Who Initiate RRT. Clin J Am Soc Nephrol 2018; 13:16-25. [PMID: 29122911 PMCID: PMC5753306 DOI: 10.2215/cjn.03610417] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 10/04/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Literature on the prognosis of patients with cirrhosis who require RRT for AKI is sparse and is confounded by liver transplant eligibility. An update on outcomes in the nonlisted subgroup is needed. Our objective was to compare outcomes in this group between those diagnosed with hepatorenal syndrome and acute tubular necrosis, stratifying by liver transplant listing status. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Retrospective cohort study of patients with cirrhosis acutely initiated on hemodialysis or continuous RRT at five hospitals, including one liver transplant center. Multivariable regression and survival analysis were performed. RESULTS Four hundred seventy-two subjects were analyzed (341 not listed and 131 listed for liver transplant). Among nonlisted subjects, 15% (51 of 341) were alive at 6 months after initiating RRT. Median survival was 21 (interquartile range [IQR], 8, 70) days for those diagnosed with hepatorenal syndrome and 12 (IQR, 3, 43) days for those diagnosed with acute tubular necrosis (P=0.25). Among listed subjects, 48% (63 of 131) received a liver transplant. Median transplant-free survival was 15 (IQR, 5, 37) days for those diagnosed with hepatorenal syndrome and 14 (IQR, 4, 31) days for those diagnosed with acute tubular necrosis (P=0.60). When stratified by transplant listing, with adjusted Cox models we did not detect a difference in the risk of death between hepatorenal syndrome and acute tubular necrosis (hazard ratio [HR], 0.81; 95% confidence interval [95% CI], 0.59 to 1.11, among those not listed; HR, 0.73; 95% CI, 0.44 to 1.19, among those listed). CONCLUSIONS Cause of AKI was not significantly associated with mortality in patients with cirrhosis who required RRT. Among those not listed for liver transplant, mortality rates were extremely high in patients both with hepatorenal syndrome and acute tubular necrosis. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_11_09_CJASNPodcast_18_1_A.mp3.
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Affiliation(s)
| | | | | | | | | | | | - Jules L. Dienstag
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Raymond T. Chung
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Abstract
Large observational databases linking kidney function and other routine patient health data are increasingly being used to study acute kidney injury (AKI). Routine health care data show an apparent rise in the incidence of population AKI and an increase in acute dialysis. Studies also report an excess in mortality and adverse renal outcomes after AKI, although with variation depending on AKI severity, baseline, definition of renal recovery, and the time point during follow-up. However, differences in data capture, AKI awareness, monitoring, recognition, and clinical practice make comparisons between health care settings and periods difficult. In this review, we describe the growing role of large databases in determining the incidence and prognosis of AKI and evaluating initiatives to improve the quality of care in AKI. Using examples, we illustrate this use of routinely collected health data and discuss the strengths, limitations, and implications for researchers and clinicians.
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Chan L, Mehta S, Chauhan K, Poojary P, Patel S, Pawar S, Patel A, Correa A, Patel S, Garimella PS, Annapureddy N, Agarwal SK, Gidwani U, Coca SG, Nadkarni GN. National Trends and Impact of Acute Kidney Injury Requiring Hemodialysis in Hospitalizations With Atrial Fibrillation. J Am Heart Assoc 2016; 5:JAHA.116.004509. [PMID: 27998917 PMCID: PMC5210405 DOI: 10.1161/jaha.116.004509] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common cause for hospitalization, but there are limited data regarding acute kidney injury requiring dialysis (AKI-D) in AF hospitalizations. We aimed to assess temporal trends and outcomes in AF hospitalizations complicated by AKI-D utilizing a nationally representative database. METHODS AND RESULTS Utilizing the Nationwide Inpatient Sample, AF hospitalizations and AKI-D were identified using diagnostic and procedure codes. Trends were analyzed overall and within subgroups and utilized multivariable logistic regression to generate adjusted odds ratios (aOR) for predictors and outcomes including mortality and adverse discharge. Between 2003 and 2012, 3751 (0.11%) of 3 497 677 AF hospitalizations were complicated by AKI-D. The trend increased from 0.3/1000 hospitalizations in 2003 to 1.5/1000 hospitalizations in 2012, with higher increases in males and black patients. Temporal changes in demographics and comorbidities explained a substantial proportion but not the entire trend. Significant comorbidities associated with AKI-D included mechanical ventilation (aOR 13.12; 95% CI 9.88-17.43); sepsis (aOR 8.20; 95% CI 6.00-11.20); and liver failure (aOR 3.72; 95% CI 2.92-4.75). AKI-D was associated with higher risk of in-hospital mortality (aOR 3.54; 95% CI 2.81-4.47) and adverse discharge (aOR 4.01; 95% CI 3.12-5.17). Although percentage mortality within AKI-D decreased over the decade, attributable risk percentage mortality remained stable. CONCLUSIONS AF hospitalizations complicated by AKI-D have quintupled over the last decade with differential increase by demographic groups. AKI-D is associated with significant morbidity and mortality. Without effective AKI-D therapies, focus should be on early risk stratification and prevention to avoid this devastating complication.
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Affiliation(s)
- Lili Chan
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Swati Mehta
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Priti Poojary
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sagar Patel
- Rutgers New Jersey Medical School, Newark, NJ
| | - Sumeet Pawar
- Boston University School of Medicine, Boston, MA
| | - Achint Patel
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ashish Correa
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shanti Patel
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | - Umesh Gidwani
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven G Coca
- Icahn School of Medicine at Mount Sinai, New York, NY
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Hung TH, Lay CJ, Tseng CW, Tsai CC, Tsai CC. The Effect of Renal Function Impairment on the Mortality of Cirrhotic Patients: A Nationwide Population-Based 3-Year Follow-up Study. PLoS One 2016; 11:e0162987. [PMID: 27631098 PMCID: PMC5025109 DOI: 10.1371/journal.pone.0162987] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 08/03/2016] [Indexed: 12/21/2022] Open
Abstract
Renal function impairment (RFI) contributes to poor prognosis in cirrhotic patients. However, there have been no studies that seek to identify the effect of different types of RFI on the mortality of cirrhotic patients. We used the National Health Insurance Database, derived from the Taiwan National Health Insurance Program, to identify 44365 cirrhotic patients between January 1, 2007 and December 31, 2007. RFI was identified in 2832 cirrhotic patients, including 1075 with acute renal failure (ARF) (169 with hepatorenal syndrome, HRS; 906 with non-hepatorenal syndrome, NHRS), 705 with chronic kidney disease (CKD), and 1052 with end stage renal disease (ESRD). After Cox proportional hazard regression analysis adjusted by gender, age, and comorbid disorders, the 30-day, 30 to 90-day, 90-day to 1-year, and 1 to 3-year mortality hazard ratios (HR) compared to the non-RFI group were: (ARF) 5.19 (4.70-5.74), 3.23 (2.76-3.77), 1.51 (1.26-1.81), and 1.35 (1.13-1.61), respectively; (CKD) 2.70 (2.30-3.18), 2.03 (1.66-2.49), 1.60 (1.34-1.90), and 1.26 (1.06-1.49), respectively; and (ESRD) 1.42 (1.17-1.72), 1.62 (1.35-1.94), 1.90 (1.68-2.15), and 1.67 (1.48-1.89), respectively. Compared to NHRS, the 30-day, 30 to 90-day, 90-day to 1-year, and 1 to 3-year mortality HRs of HRS were 1.03 (0.80-1.32), 2.13 (1.46-3.11), 1.58 (0.90-2.75), and 2.51 (1.41-4.48), respectively, in cirrhotic patients with ARF. These results indicate the effects of CKD and ESRD on the mortality of cirrhotic patients are distributed equally in every survival stage, whereas the effect of ARF appears only in the early stage. Compared to NHRS, HRS contributes to a higher mortality risk at the late survival stage.
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Affiliation(s)
- Tsung-Hsing Hung
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chorng-Jang Lay
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Infectious diseases, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Chih-Wei Tseng
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Chun Tsai
- Department of Mathematics, Tamkang University, Tamsui, Taiwan
| | - Chen-Chi Tsai
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Infectious diseases, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- * E-mail:
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Kanda T. Interferon-free treatment for HCV-infected patients with decompensated cirrhosis. Hepatol Int 2016; 11:38-44. [PMID: 27282879 DOI: 10.1007/s12072-016-9749-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 05/27/2016] [Indexed: 02/06/2023]
Abstract
Progress in interferon-free treatment against hepatitis C virus (HCV) has remained a challenge in patients with decompensated cirrhosis due to a paucity of information on efficacy and safety profiles. This review illustrates that interferon-free treatment could result in greater than 85 % sustained virological response (SVR) rates in patients with HCV genotype 1 and decompensated cirrhosis. The combination of pangenotypic HCV NS5A inhibitor velpatasvir and HCV NS5B inhibitor sofosbuvir has demonstrated high SVR rates in patients with HCV genotypes 1, 2, 3, 4 or 6 and decompensated cirrhosis. Certain patients discontinued treatment due to adverse events, death or having liver transplantation. Taken together, interferon-free treatment could produce higher SVR rates in decompensated hepatic cirrhosis. However, as adverse events were occasionally observed, liver transplantation should always be considered as well. Further improvements in treatment are called for in patients with decompensated cirrhosis.
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Affiliation(s)
- Tatsuo Kanda
- Department of Gastroenterology and Nephrology, Chiba University, Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 220-8677, Japan.
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