Acute kidney injury network criteria as a predictor of hospital mortality in cirrhotic patients with ascites

Hillien SA, Robinson JE, Chung RT, Cullaro G, Karvellas CJ, Levitsky J, Orman ES, Patidar KR, Regner KR, Saly DL, Sawinski D, Sharma P, Teixeira JP, Ufere NN, Velez JCQ, Wadei HM, Wahid N, Allegretti AS, Neyra JA, Belcher JM. Association of Hepatorenal Syndrome-Acute Kidney Injury with Mortality in Patients with Cirrhosis Requiring Renal Replacement Therapy: Results from the HRS-HARMONY Consortium

Key Points

In patients with cirrhosis and AKI requiring renal replacement therapy (RRT), hepatorenal syndrome-AKI was not associated with an increased 90-day mortality when compared with other AKI etiologies. Etiology of AKI may not be a critical factor regarding decisions to trial RRT in acutely ill patients with cirrhosis and AKI. Although elevated, mortality rates in this study are comparable with those reported in general hospitalized patients with AKI requiring RRT.

Background

While AKI requiring renal replacement therapy (AKI-RRT) is associated with increased mortality in heterogeneous inpatient populations, the epidemiology of AKI-RRT in hospitalized patients with cirrhosis is not fully known. Herein, we evaluated the association of etiology of AKI with mortality in hospitalized patients with cirrhosis and AKI-RRT in a multicentric contemporary cohort.

Methods

This is a multicenter retrospective cohort study using data from the HRS-HARMONY consortium, which included 11 US hospital network systems. Consecutive adult patients admitted in 2019 with cirrhosis and AKI-RRT were included. The primary outcome was 90-day mortality, and the main independent variable was AKI etiology, classified as hepatorenal syndrome (HRS-AKI) versus other (non–HRS-AKI). AKI etiology was determined by at least two independent adjudicators. We performed Fine and Gray subdistribution hazard analyses adjusting for relevant clinical variables.

Results

Of 2063 hospitalized patients with cirrhosis and AKI, 374 (18.1%) had AKI-RRT. Among them, 65 (17.4%) had HRS-AKI and 309 (82.6%) had non–HRS-AKI, which included acute tubular necrosis in most cases (62.6%). Continuous renal replacement therapy was used as the initial modality in 264 (71%) of patients, while intermittent hemodialysis was used in 108 (29%). The HRS-AKI (versus non–HRS-AKI) group received more vasoconstrictors for HRS management (81.5% versus 67.9%), whereas the non–HRS-AKI group received more mechanical ventilation (64.3% versus 50.8%) and more continuous renal replacement therapy (versus intermittent hemodialysis) as the initial RRT modality (73.9% versus 56.9%). In the adjusted model, HRS-AKI (versus non–HRS-AKI) was not independently associated with increased 90-day mortality (subdistribution hazard ratio, 1.36; 95% confidence interval, 0.95 to 1.94).

Conclusions

In this multicenter contemporary cohort of hospitalized adult patients with cirrhosis and AKI-RRT, HRS-AKI was not independently associated with an increased risk of 90-day mortality when compared with other AKI etiologies. The etiology of AKI appears less relevant than previously considered when evaluating the prognosis of hospitalized adult patients with cirrhosis and AKI requiring RRT.

Acute Kidney Injury in Chronic Liver Disease in Northwest India: Still a Battle to Conquer

Background

Patients with cirrhosis are susceptible to development of acute kidney injury (AKI), which leads to poor outcome. We conducted a study to evaluate the spectrum of AKI in patients with cirrhosis.

Materials and Methods

This study was conducted in consecutive cirrhotic patients with AKI admitted in a tertiary care center of India from April 2020 to December 2022. Details including history, examination findings, and results of laboratory investigations were recorded.

Results

A total of 243 patients were enrolled in this study. The majority (91.3%) of the patients were males. The most common etiology of cirrhosis was alcohol in 58.4% (n = 142) followed by hepatitis B in 10.3% (n = 25) of patients. Pre-renal form of AKI was present in 54.4% (n = 132) of patients and hepatorenal syndrome (HRS) in 21.8% (n = 53) of patients. IgA nephropathy was the commonest (n = 6) glomerular pathology in nonresponders with intrinsic renal disease. Majority of the patients belonged to stage II (46.9%) and stage I AKI (37%), while only 16.1% had stage III AKI. Various stages of AKI showed a significant correlation (P < 0.05) with Child-Turcotte-Pugh (CTP) score and Model for End-stage Liver Disease (MELD)-Na score. The overall in-hospital mortality rate was found to be 18.5% (n = 45).

Conclusion

Renal dysfunction is a frequent complication among cirrhotic patients. Pre-renal factors were the most common cause of AKI in cirrhotics. Stages of AKI showed significant correlation with liver prognostic scores. Renal biopsy should be considered in patients not responding to treatment, to guide further management.

Understanding the relationship between HCV infection and progression of kidney disease

Hepatitis C virus (HCV) can cause a range of kidney diseases. HCV is the primary cause of mixed cryoglobulinaemia, which leads to cryoglobulinaemic vasculitis and cryoglobulinaemic glomerulonephritis (GN). Patients with acute cryoglobulinaemic vasculitis often exhibit acute kidney disease due to HCV infection, which typically progresses to acute kidney injury (AKI). HCV also increases the risk of chronic kidney disease (CKD) and the likelihood of developing end-stage renal disease (ESRD). Currently, direct-acting antiviral agents (DAAs) can be used to treat kidney disease at different stages. This review focuses on key findings regarding HCV and kidney disease, discusses the impact of DAAs, and highlights the need for further research and treatment.

Hepatorenal Syndrome Type 1: Diagnosis and Treatment

Hepatorenal syndrome (HRS) is a feared complication in patients with advanced cirrhosis and is associated with significant morbidity and mortality. While recognized as a distinct physiologic condition for well over one hundred years, a lack of objective diagnostic tests has made the diagnosis one of exclusion. Since 1979, multiple sets of diagnostic criteria have been proposed. Though varying in detail, the principal intent of these criteria is to identify patients with severe, functional acute kidney injury that is unresponsive to volume resuscitation and exclude those with structural injury. However, accurate differential diagnosis remains challenging. Recently, multiple urinary biomarkers of kidney injury, including neutrophil gelatinase-associated lipocalin, have been studied as a means of objectively phenotyping etiologies of acute kidney injury in patients with cirrhosis. Along with markers reflecting tubular functional integrity, including the fractional excretion of sodium, injury markers will likely be incorporated into future diagnostic criteria. Making an accurate diagnosis is critical, as therapeutic options exist for HRS but must be given in a timely manner and only to those patients likely to benefit. Terlipressin, an analog of vasopressin, is the first line of therapy for HRS in much of the world and has recently been approved for use in the United States. Significant questions remain regarding the optimal dosing strategy, metrics for titration, and the potential role of point-of-care ultrasound to help guide concurrent albumin administration.

Update on Assessment of Estimated Glomerular Filtration Rate in Patients With Cirrhosis

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.

Determinants of Short-term Mortality in Liver Cirrhosis with Acute Kidney Injury: A Prospective Observational Study

Background: Acute kidney injury (AKI) occurs in 20-50% of patients with cirrhosis and is associated with a poor prognosis. The aim of the study is to identify the baseline factors affecting mortality in these patients at 30 and 90 days. Methods: We enrolled 117 patients with cirrhosis and AKI and followed them up prospectively. Results: Distribution of International club of ascites AKI stages was: 26 (22.03%) stage 1, 59 (50%) stage 2, and 33 (28%) stage 3. Mortalities at 30 and 90 days were 27 (22.8%) and 33 (27.9%) respectively. On multivariate analysis, variables affecting mortality at 30 days were serum creatinine level>2 mg% at 48 hours after AKI development (adjusted OR 7.93, P=0.02) and leukocytosis (total leucocyte count>11000/mm3 ) at admission (adjusted OR 6.54, P=0.002). Only leukocytosis at admission was a predictor of 90 days mortality (adjusted OR 4.76, P=0.01). Though not statistically significant, patients not responding to standard medical treatment had 3 times higher mortality at 30 days, while the maximum AKI stages (2 and 3) had eight times higher mortality at 90 days. Conclusion: In cirrhosis, AKI increases short-term mortality. High serum creatinine at 48 hours affects mortality at 30 days, while leukocytosis at baseline predicts mortality at 30 and 90 days. Progression to a higher AKI stage impacts prognosis.

Management of hepatorenal syndrome in liver cirrhosis: a recent update

Hepatorenal syndrome (HRS) is a serious form of renal dysfunction in patients with cirrhosis and ascites. It is an important component of the acute-on-chronic liver failure (ACLF) syndrome. Significant recent changes in the understanding of the pathophysiology of renal dysfunction in cirrhosis include the role of inflammation in addition to hemodynamic changes. The term acute kidney injury (AKI) is now adopted to include all functional and structural forms of acute renal dysfunction in cirrhosis, with various stages describing the severity of the condition. Type 1 hepatorenal syndrome (HRS1) is renamed HRS-AKI, which is stage 2 AKI [doubling of baseline serum creatinine (sCr)] while fulfilling all other criteria of HRS1. Albumin is used for its volume expanding and anti-inflammatory properties to confirm the diagnosis of HRS-AKI. Vasoconstrictors are added to albumin as pharmacotherapy to improve the hemodynamics. Terlipressin, although not yet available in North America, is the most common vasoconstrictor used worldwide. Patients with high grade of ACLF treated with terlipressin are at risk for respiratory failure if there is pretreatment respiratory compromise. Norepinephrine is equally effective as terlipressin in reversing HRS1. Recent data show that norepinephrine may be administered outside the intensive care setting, but close monitoring is still required. There has been no improvement in overall or transplant-free survival shown with vasoconstrictor use, but response to vasoconstrictors with reduction in sCr is associated with improvement in survival. Non-responders to vasoconstrictor plus albumin will need liver transplantation as definite treatment with renal replacement therapy as a bridge therapy. Combined liver and kidney transplantation is recommended for patients with prolonged history of AKI, underlying chronic kidney disease or with hereditary renal conditions. Future developments, such as the use of biomarkers and metabolomics, may help to identify at risk patients with earlier diagnosis to allow for earlier treatment with improved outcomes.

Outcomes of septic cirrhosis patients admitted to the intensive care unit: A retrospective cohort study

The aim of this study is to examine the outcome of septic patients with cirrhosis admitted to the intensive care unit (ICU) and predictors of mortality.Single center, retrospective cohort study.The study was conducted in Intensive care Department of King Abdulaziz Medical City, Riyadh, Saudi Arabia.Data was extracted from a prospectively collected ICU database managed by a full time data collector. All patients with an admission diagnosis of sepsis according to the sepsis-3 definition were included from 2002 to 2017. Patients were categorized into 2 groups based on the presence or absence of cirrhosis.The primary outcome of the study was in-hospital mortality. Secondary outcomes included ICU mortality, ICU and hospital lengths of stay and mechanical ventilation duration.A total of 7906 patients were admitted to the ICU with sepsis during the study period, of whom 497 (6.29%) patients had cirrhosis. 64.78% of cirrhotic patients died during their hospital stay compared to 31.54% of non-cirrhotic. On multivariate analysis, cirrhosis patients were at greater odds of dying within their hospital stay as compared to non-cirrhosis patients (Odds ratio {OR} 2.53; 95% confidence interval {CI} 2.04 - 3.15) independent of co-morbidities, organ dysfunction or hemodynamic status. Among cirrhosis patients, elevated international normalization ratio (INR) (OR 1.69; 95% CI 1.29-2.23), hemodialysis (OR 3.09; 95% CI 1.76-5.42) and mechanical ventilation (OR 2.61; 95% CI 1.60-4.28) were the independent predictors of mortality.Septic cirrhosis patients admitted to the intensive care unit have greater odds of dying during their hospital stay. Among septic cirrhosis patients, elevated INR and the need for hemodialysis and mechanical ventilation were associated with increased mortality.

Acute kidney injury and hepatorenal syndrome in cirrhosis

Acute kidney injury (AKI) in cirrhosis, including hepatorenal syndrome (HRS), is a common and serious complication in cirrhotic patients, leading to significant morbidity and mortality. AKI is separated into two categories, non-HRS AKI and HRS-AKI. The most recent definition and diagnostic criteria of AKI in cirrhosis and HRS have helped diagnose and prognosticate the disease. The pathophysiology behind non-HRS-AKI and HRS is more complicated than once theorized and involves more processes than just splanchnic vasodilation. The common biomarkers clinicians use to assess kidney injury have significant limitations in cirrhosis patients; novel biomarkers being studied have shown promise but require further studies in clinical settings and animal models. The overall management of non-HRS AKI and HRS-AKI requires a systematic approach. Although pharmacological treatments have shown mortality benefit, the ideal HRS treatment option is liver transplantation with or without simultaneous kidney transplantation. Further research is required to optimize pharmacologic and nonpharmacologic approaches to treatment. This article reviews the current guidelines and recommendations of AKI in cirrhosis.

A Review of Hepatorenal Syndrome

The development of acute kidney injury (AKI) is one of the most frequent complications in patients with cirrhosis. AKI due to volume depletion is the most common etiology and hepatorenal syndrome (HRS) is the second most common cause of AKI in these patients. HRS is the extreme form of kidney injury in patients with cirrhosis, which is caused due to a reduction in renal blood flow unresponsive to volume expansion. The literature involving HRS is rapidly evolving and newer tests and updated definitions have been proposed which allows timely identification and treatment. Here, we will discuss the definition, pathophysiology, prevention, diagnosis, and treatment of HRS.

Recent advances in the understanding and management of hepatorenal syndrome

Renal dysfunction occurs frequently in hospitalized patients with advanced chronic liver disease (ACLD)/cirrhosis and has profound prognostic implications. In ACLD patients with ascites, hepatorenal syndrome (HRS) may result from circulatory dysfunction that leads to reduced kidney perfusion and glomerular filtration rate (in the absence of structural kidney damage). The traditional subclassification of HRS has recently been replaced by acute kidney injury (AKI) type of HRS (HRS-AKI) and non-AKI type of HRS (HRS-NAKI), replacing the terms “HRS type 1” and “HRS type 2”, respectively. Importantly, the concept of absolute serum creatinine (sCr) cutoffs for diagnosing HRS was partly abandoned and short term sCr dynamics now may suffice for AKI diagnosis, which facilitates early treatment initiation that may prevent the progression to HRS-AKI or increase the chances of AKI/HRS-AKI reversal. Recent randomized controlled trials have established (a) the efficacy of (long-term) albumin in the prevention of complications of ascites (including HRS-AKI), (b) the benefits of transjugular intrahepatic portosystemic shunt placement in patients with recurrent ascites, and (c) the superiority of terlipressin over noradrenaline for the treatment of HRS-AKI in the context of acute-on-chronic liver failure. This review article aims to summarize recent advances in the understanding and management of HRS.

INASL-ISN Joint Position Statements on Management of Patients with Simultaneous Liver and Kidney Disease

Renal dysfunction is very common among patients with chronic liver disease, and concomitant liver disease can occur among patients with chronic kidney disease. The spectrum of clinical presentation and underlying etiology is wide when concomitant kidney and liver disease occur in the same patient. Management of these patients with dual onslaught is challenging and requires a team approach of hepatologists and nephrologists. No recent guidelines exist on algorithmic approach toward diagnosis and management of these challenging patients. The Indian National Association for Study of Liver (INASL) in association with Indian Society of Nephrology (ISN) endeavored to develop joint guidelines on diagnosis and management of patients who have simultaneous liver and kidney disease. For generating these guidelines, an INASL-ISN Taskforce was constituted, which had members from both the societies. The taskforce first identified contentious issues on various aspects of simultaneous liver and kidney diseases, which were allotted to individual members of the taskforce who reviewed them in detail. A round-table meeting of the Taskforce was held on 20-21 October 2018 at New Delhi to discuss, debate, and finalize the consensus statements. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications. The strength of recommendations (strong and weak) thus reflects the quality (grade) of underlying evidence (I, II, III). We present here the INASL-ISN Joint Position Statements on Management of Patients with Simultaneous Liver and Kidney Disease.

[Chronic kidney injury in patients with liver diseases - Reappraising pathophysiology and treatment options]

Acute and chronic kidney disease concurs commonly with liver disease and is associated with a wide array of complications including dialysis dependency and increased mortality. Patients with liver disease or liver cirrhosis show a higher prevalence of chronic kidney disease. This is attributed to concomitant comorbidities, such as metabolic syndrome, chronic inflammation, hypercoagulability, hyperfibrinolysis, diabetes mellitus and dyslipidaemias. But chronic progressive kidney disease is not always due to hepatorenal syndrome. Beyond that, other diseases or disease entities should be considered. Among them are diabetic nephropathy, secondary IgA nephropathy, hepatitis C -associated membranoproliferative Glomerulonephritis (MPGN) and hepatitis B-associated membranous nephropathy.Coexisting diseases, similar underlying pathophysiologic mechanisms, or simultaneously concurring pathophysiological processes and overlapping clinical manifestations, impede the etiologic diagnosis and corresponding treatment of chronic kidney disease in the setting of chronic liver disease. In this review, we focus on common and rare pathologies, which can lead to chronic kidney disease in this particular patient group and try to summarize the most recent therapeutic modalities.

Acute kidney injury among salicylate intoxication hospitalisations in the United States

BACKGROUND

This study aimed to evaluate the risk factors and the association of acute kidney injury (AKI) with outcomes, and resource utilisation in patients hospitalised because of salicylate intoxication in the United States.

METHODS

Hospitalised patients with a primary diagnosis of salicylate intoxication from 2003 to 2014 were identified in the National Inpatient Sample (NIS) database. End-stage kidney disease patients were excluded. The occurrence of AKI was identified using hospital diagnosis code. Clinical characteristics, in-hospital treatment, outcomes and resource utilisation were compared between patients with and without AKI.

RESULTS

A total of 13 787 eligible hospital admissions were included in the analysis. AKI occurred in 1279 (9.3%) admissions. Older age, male sex, more recent year of hospitalisation, anaemia, hypertension, congestive heart failure, chronic kidney disease, volume depletion, sepsis and ventricular arrhythmia/cardiac arrest were significantly associated with increased risk of AKI, whereas Hispanic race was associated with decreased risk. AKI was significantly associated with increased risk of organ failure, and in-hospital mortality. In addition, the need for ventilation support, blood component transfusion, renal replacement therapy, length of hospital stay and hospitalisation cost were higher in AKI patients.

CONCLUSION

Approximately one tenth of salicylate intoxication patients developed AKI during hospitalisation. AKI was associated with higher morbidity, mortality and resource utilisations.

Acute kidney injury in hospitalized cirrhotic patients: Risk factors, type of kidney injury, and survival

Background and Aim

Acute kidney injury (AKI) is a common complication of chronic liver disease (CLD). We performed a prospective study to evaluate the risk factors and spectrum of AKI among decompensated cirrhosis (DC) patients and the impact of AKI on survival.

Methods

This study was conducted in consecutive DC patients hospitalized in SCB Medical College between December 2016 and October 2018. AKI was defined as per ICA criteria. Demographic, clinical, and laboratory parameters and outcomes were compared between patients with and without AKI.

Results

A total of 576 DC subjects were enrolled, 315 (54.69%) of whom had AKI; 34% (n = 106) had stage 1A, 28% (n = 90) stage 1B, 21% (n = 65) stage 2, and 17% (n = 54) stage 3 AKI. Alcohol was the predominant cause of CLD (66.7%). In 207 (65.7%) patients, diuretic/lactulose/nonsteroidal anti‐inflammatory drugs use was noted, and infection was present in 190 (60.3%) patients. Compared to those without AKI, patients with AKI had higher leucocyte count, higher serum urea and creatinine, higher Child‐Turcotte‐Pugh, higher Model of End‐Stage Liver Disease (MELD) scores (P < 0.001), longer hospital stay, and lower survival at 28 days and 90 days (P < 0.001). Besides, in patients with stages 1A to 3 AKI, there were differences in overall survival at 28 days (P < 0.001) and 90 days (P < 0.001).

Conclusions

Over half of DC patients had AKI, and alcohol was the most common cause of cirrhosis in them. Use of AKI‐precipitating medications was the most common cause of AKI, followed by bacterial infection. AKI patients had increased prevalence of acute‐on‐chronic liver failure and had prolonged hospitalization and lower survival both at 28 days and 90 days.

Effect of acute kidney injury on the patients with hepatocellular carcinoma undergoing transarterial chemoembolization

The purpose of this study was to investigate the effect of acute kidney injury (AKI) on the prognosis of patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). A total of 347 HCC patients with Child-Pugh class A and pre-TACE serum creatinine (SCr) ≤1.5 mg/dL undergoing TACE as an initial therapy 2000-2014 were analyzed. Overall survival with related risk factors including AKI was investigated. We assessed AKI based on the International Club of Ascites (ICA)-AKI criteria. The mean age was 60.9 years. Of 347 patients, death was observed in 109 patients (31.4%). The mean SCr levels at pre-TACE, one day, two months, and four months after TACE were 0.9, 0.9, 0.9, and 1.1 mg/dL, respectively. The AKI within four months after TACE developed in 37 patients (11%). The AKI stages were non-AKI in 310 (89%), stage 1 in 10 (3%), stage 2 in 10 (3%), and stage 3 in 17 patients (5%). Multivariable analysis showed that the risk factors for overall survival were serum albumin ≤3.5 g/dL (hazard ratio [HR] 1.58, p = 0.027), BCLC stage B (HR 2.07, p = 0.008), BCLC stage C (HR 3.96, p<0.001), bilobar tumor location (HR 1.66, p = 0.022), AKI stage 1 (HR 6.09, p<0.001), AKI stage 2 (HR 8.51, p<0.001), and AKI stage 3 (HR 17.64, p<0.001). AKI is a crucial prognostic factor for overall survival in HCC patients undergoing TACE. The assessment of AKI based on the ICA-AKI criteria can facilitate evaluation of the prognosis of HCC patients undergoing TACE.

Could KIM-1 and NGAL levels predict acute kidney injury after paracentesis? - preliminary study

BACKGROUND

Kidney dysfunction is a common complication in patients with severe liver cirrhosis. There is a need for discovery and validation of novel biomarkers for earlier AKI detection. The aim of this study was to determine if tubular injury markers: NGAL and KIM-1 could be helpful in the early diagnosis of AKI in patients undergoing therapeutic paracentesis.

METHODS

This preliminary study included 24 adult patients diagnosed with liver cirrhosis who had been hospitalized due to massive ascites requiring paracentesis. Pre- and post-paracentesis plasma samples were taken from each patient and biomarkers were measured.

RESULTS

Before paracentesis, the levels of serum and urinary NGAL were similar between patients and controls; while urinary KIM-1 was markedly increased in liver cirrhotic patients (0.76 vs. 0.24 ng/ml; respectively). Although urinary NGAL levels in AKI patients were 5-time greater than in non-AKI subgroup, the difference did not reach statistical significance (13.2 vs 1.5 pg/mL, p = 0.06). Serum NGAL level, post-procedure, was 3 times greater in AKI subgroup.

CONCLUSION

Kidney injury markers, especially serum NGAL, may be useful for the early detection of AKI. However, further research is required to determine if biomarkers of kidney injury may help identify patients with cirrhosis who would most likely benefit from early AKI prevention and treatment.

Short-term mortality in patients with cirrhosis of the liver and acute kidney injury: A prospective observational study

INTRODUCTION

Renal failure is a common and severe complication of cirrhosis and confers poor prognosis. Serum creatinine is the most practical biomarker of renal function. Serum creatinine estimation in cirrhosis of the liver is affected by decreased formation, increased tubular secretion, increased volume of distribution, and interference by elevated bilirubin. Studies on the prognosis of cirrhotic patients using creatinine kinetics as a definition of acute kidney injury (AKI) proposed by the International Ascites Club are limited.

METHODS

In this single-center prospective observational study, decompensated cirrhotics with AKI defined by the International Ascites Club as the rise of serum creatinine ≥ 0.3 mg/dL within 48 h of admission or increase of serum creatinine ≥ 50% from stable baseline creatinine over the previous 3 months were followed and assessed for the development of complications during hospital course and in-hospital and 30-day mortality.

RESULTS

AKI developed in 142 out of 499 (28.45%) patients with cirrhosis. Twenty patients were excluded. The most common etiology of cirrhosis was alcohol (n = 64, 52%), and ascites was present in 115 (94%) patients. Eighty-two (67.21%) patients presented with AKI at the time of admission. Thirty-day mortality was 46.72% (57/122 patients). Hepatorenal syndrome had the highest mortality followed by AKI related to infection. Presence of jaundice and hepatic encephalopathy (HE) was associated with poor survival with adjusted hazard ratio of 3.54 and 2.17, respectively. On bivariate logistic regression analysis, jaundice, HE, type of AKI, AKI stage at maximum creatinine, bilirubin, serum glutamic oxaloacetic transaminase (SGOT), international normalized ratio (INR), and Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) scores were predictors of mortality (p < 0.05). Sensitivity, specificity, and accuracy of MELD > 29 and CTP score > 11 were 75.44%, 82%, and 78.70% and 66.67%, 81.54%, and 74.60%, respectively for predicting 30-day mortality.

CONCLUSION

Development of AKI as defined by the International Ascites Club in cirrhosis confers high short-term mortality. Jaundice, HE, AKI stage, creatinine at enrollment, bilirubin, CTP, and MELD score were the predictors of mortality. Bullet points of the study highlights What is already known? • Renal failure is a common and severe complication of cirrhosis. • Serum creatinine is the most practical biomarker of renal function but it has many limitations in cirrhotic patients. • Creatinine kinetics-based definition of acute kidney injury (AKI) was proposed by the International Ascites Club. What is new in this study? • Short-term mortality (30 days) in decompensated cirrhotic patients with AKI as defined by the International Ascites Club using creatinine kinetics was high. • AKI due to hepatorenal syndrome (HRS) has the highest short-term (30 days) mortality followed by AKI due to infection in decompensated cirrhosis. • Detection of AKI using creatinine kinetics-based definition may prompt an early appropriate intervention. What are the future clinical and research implications of study findings? • Creatinine kinetics-based definition of AKI diagnose renal injury at an earlier stage; an appropriate intervention should be initiated at the earliest in these patients to improve patient survival.

Terlipressin May Decrease In-Hospital Mortality of Cirrhotic Patients with Acute Gastrointestinal Bleeding and Renal Dysfunction: A Retrospective Multicenter Observational Study

BACKGROUND

Acute gastrointestinal bleeding (GIB) rapidly reduces effective blood volume, thereby precipitating acute kidney injury (AKI). Terlipressin, which can induce splanchnic vasoconstriction and increase renal perfusion, has been recommended for acute GIB and hepatorenal syndrome in liver cirrhosis. Thus, we hypothesized that terlipressin might be beneficial for cirrhotic patients with acute GIB and renal impairment.

METHODS

In this Chinese multi-center study, 1644 cirrhotic patients with acute GIB were retrospectively enrolled. AKI was defined according to the International Club of Ascites (ICA) criteria. Renal dysfunction was defined as serum creatinine (sCr) > 133 μmol/L at admission and/or any time point during hospitalization. Incidence of renal impairment and in-hospital mortality were the primary end-points.

RESULTS

The incidence of any stage ICA-AKI, ICA-AKI stages 1B, 2, and 3, and renal dysfunction in cirrhotic patients with acute GIB was 7.1%, 1.8%, and 5.0%, respectively. The in-hospital mortality was significantly increased by renal dysfunction (14.5% vs. 2.2%, P < 0.001) and ICA-AKI stages 1B, 2, and 3 (11.1% vs. 2.8%, P = 0.011), but not any stage ICA-AKI (5.7% vs. 2.7%, P = 0.083). The in-hospital mortality was significantly decreased by terlipressin in patients with renal dysfunction (3.6% vs. 20.0%, P = 0.044), but not in those with any stage ICA-AKI (4.5% vs. 6.0%, P = 0.799) or ICA-AKI stages 1B, 2, and 3 (0.0% vs. 14.3%, P = 0.326).

CONCLUSION

Renal dysfunction increased the in-hospital mortality of cirrhotic patients with acute GIB. Terlipressin might decrease the in-hospital mortality of cirrhotic patients with acute GIB and renal dysfunction.

TRIAL REGISTRATION

NCT03846180 ( https://clinicaltrials.gov ).

Hepatorenal syndrome: pathophysiology, diagnosis, and management

Hepatorenal syndrome (HRS), the extreme manifestation of renal impairment in patients with cirrhosis, is characterized by reduction in renal blood flow and glomerular filtration rate. Hepatorenal syndrome is diagnosed when kidney function is reduced but evidence of intrinsic kidney disease, such as hematuria, proteinuria, or abnormal kidney ultrasonography, is absent. Unlike other causes of acute kidney injury (AKI), hepatorenal syndrome results from functional changes in the renal circulation and is potentially reversible with liver transplantation or vasoconstrictor drugs. Two forms of hepatorenal syndrome are recognized depending on the acuity and progression of kidney injury. The first represents an acute impairment of kidney function, HRS-AKI, whereas the second represents a more chronic kidney dysfunction, HRS-CKD (chronic kidney disease). In this review, we provide critical insight into the definition, pathophysiology, diagnosis, and management of hepatorenal syndrome.

Effect of acute kidney injury on long-term outcomes of spontaneous bacterial peritonitis in cirrhotic patients using the International Club of Ascites-acute kidney injury criteria

BACKGROUND AND AIM

This study aimed to investigate the effect of acute kidney injury (AKI) on long-term mortality of spontaneous bacterial peritonitis (SBP) in cirrhotic patients using International Club of Ascites (ICA)-AKI criteria.

METHODS

A total of 157 cirrhotic patients with a first episode of SBP between 2007 and 2016 were analyzed. We investigated the long-term mortality with related risk factors of SBP in cirrhosis including the ICA-AKI criteria. The ICA-AKI stage at SBP diagnosis is evaluated by stages 0-3. Stage progression was defined as a progression of AKI to a higher stage.

RESULTS

The ICA-AKI stage at the diagnosis of SBP was stage 0 in 91 (58%), stage 1 in 33 (21%), stage 2 in 19 (12%), and stage 3 in 14 patients (9%). Stage progression within 48 h after SBP diagnosis was noted in 18 patients (12%). Multivariable analysis showed that the risk factors for overall survival were age ≥ 60 years (hazard ratio [HR] 1.74, P = 0.029), serum sodium ≤ 130 mmol/L (HR 1.3, P = 0.017), ICA-AKI stage 1 (HR 2.51, P = 0.003), ICA-AKI stage 2 or 3 (HR 3.36, P < 0.001), and stage progression at 48 h after SBP diagnosis (HR 2.57, P = 0.004). The differences in overall survival using the ICA-AKI in patients without AKI using the conventional criteria were significantly different (P = 0.019).

CONCLUSION

Acute kidney injury and its progression are significant risk factors for mortality in cirrhotic patients with SBP. The application of the ICA-AKI criteria is important and advantageous for early evaluation and intervention for a better prognosis in cirrhotic patients with SBP.

Diagnostics, Risk Factors, Treatment and Outcomes of Acute Kidney Injury in a New Paradigm

Acute kidney injury (AKI) is a common clinical condition among patients admitted in the hospitals. The condition is associated with both increased short-term and long-term mortality. With the development of a standardized definition for AKI and the acknowledgment of the impact of AKI on patient outcomes, there has been increased recognition of AKI. Two advances from past decades, the usage of computer decision support and the discovery of AKI biomarkers, have the ability to advance the diagnostic method to and further management of AKI. The increasingly widespread use of electronic health records across hospitals has substantially increased the amount of data available to investigators and has shown promise in advancing AKI research. In addition, progress in the finding and validation of different forms of biomarkers of AKI within diversified clinical environments and has provided information and insight on testing, etiology and further prognosis of AKI, leading to future of precision and personalized approach to AKI management. In this this article, we discussed the changing paradigms in AKI: from mechanisms to diagnostics, risk factors, and management of AKI.

Use of Nonselective β-Blockers in Patients With End-Stage Liver Disease and Select Complications

Objective: To review the literature and recommendations for nonselective β-blockers (NSBBs) in the setting of variceal bleeding prophylaxis and decompensated liver disease. Data Sources: Literature search of MEDLINE was performed (1988 to October 2019) using the following search terms: cirrhosis, advanced cirrhosis, β-blocker, decompensation, prophylaxis. Abstracts, peer-reviewed publications, clinical practice guidelines, and product monographs were reviewed. Study Selection and Data Extraction: Relevant English language studies and those conducted in humans were considered for analysis and inclusion. Data Synthesis: Evidence that suggests that NSBBs are harmful in advanced cirrhosis is overshadowed by confounding variables and small patient populations. The majority of the available evidence suggests neutral or beneficial effects on mortality with continuation of NSBBs despite liver disease progression. Based on the available literature, guidelines, and expert consensuses, NSBBs can be considered within this patient population and may have a positive impact on the majority of these patients. Relevance to Patient Care and Clinical Practice: This review summarizes current place in therapy for NSBBs in the setting of cirrhosis and variceal bleeding prophylaxis. It also includes a discussion of the literature for use of NSBBs within the setting of different acute decompensations in which the data and recommendations for use are less clear. Conclusions: Recent evidence shows neutral or positive results for NSBB use in particular decompensation subgroups, which suggests that NSBBs can be used cautiously with close monitoring in patients with advanced cirrhosis. Questions still remain regarding optimal agent and dose and whether agents can be safely restarted after an acute decompensation episode.

Biomarkers for acute kidney injury in decompensated cirrhosis: A prospective study

AIM

Acute kidney injury (AKI) is a frequent complication in cirrhotic patients. As serum creatinine is a poor marker of renal function in this population, we aimed to study the utility of several biomarkers in this context.

METHODS

A prospective study was conducted in hospitalized patients with decompensated cirrhosis. Serum creatinine (SCr), Cystatin C (CystC), NGAL and urinary NGAL, KIM-1, protein, albumin and sodium were measured on three separate occasions. Renal resistive index (RRI) was obtained. We analyzed the value of these biomarkers to determine the presence of AKI, its aetiology [prerenal, acute tubular necrosis (ATN), or hepatorenal (HRS)], its severity and a composite clinical outcome at 30 days (death, dialysis and intensive care admission).

RESULTS

We included 105 patients, of which 55 had AKI. SCr, CystC, NGAL (plasma and urinary), urinary sodium and RRI at inclusion were independently associated with the presence of AKI. SCr, CystC and plasma NGAL were able to predict the subsequent development of AKI. Pre-renal state showed lower levels of SCr, NGAL (plasma and urinary) and RRI. ATN patients had high levels of NGAL (plasma and urinary) as well as urinary protein and sodium. HRS patients presented an intermediate pattern. All biomarkers paralleled the severity of AKI. SCr, CystC and plasma NGAL predicted the development of the composite clinical outcome with the same performance as the MELD score.

CONCLUSIONS

In patients with decompensated cirrhosis, early measurement of renal biomarkers provides valuable information on AKI aetiology. It could also improve AKI diagnosis and prognosis.

Clinical Aspects and Prognosis Evaluation of Cirrhotic Patients Hospitalized with Acute Kidney Injury

BACKGROUND

Acute kidney injury occurs in approximately 20% of hospitalized cirrhotic patients. Mortality is estimated at 60% within a month and 65% within a year.

AIMS

To evaluate survival in 30 days and in 3 months of cirrhotic patients hospitalized with acute kidney injury, identifying factors associated with mortality.

METHODS

52 patients with cirrhosis admitted to an academic tertiary center who presented acute kidney injury according to the International Club of Ascites criteria were evaluated. Clinical and laboratory data was collected at diagnosis between 2011 and 2015.

RESULTS

Average age was 54.6 (±10.7) years and 69.2% were male. The average MELD, MELD-Na, and Child-Pugh scores were 21.9 (±7.0), 24.5 (±6.7), and 10.1 (±2.2), respectively. Thirty patients (57.7%) were in acute kidney injury stage 1, 16 (30.8%) in stage 2, and six (11.6%) in stage 3. Mortality was 28.6% in 30 days and 44.9% in three months. In multivariate analysis, variables that were associated independently to mortality were lack of response to expansion treatment and Child-Pugh score. Mortality was 93.3% in three months among nonresponders compared to 28.6% among those who responded to volume expansion (p<0.0001).

CONCLUSION

Acute kidney injury in cirrhosis has dire prognosis, particularly in patients with advanced cirrhosis and in nonresponders to volume expansion.

Validation of International Club of Ascites subclassification of stage 1 acute kidney injury in chronic liver disease

Background and Aim

Acute kidney injury (AKI) commonly occurs in patients with chronic liver disease (CLD). As per the International Club of Ascites, AKI is classified into three stages; stage 1 has recently been divided into subgroups 1A and 1B. We performed a prospective study to validate the association between subgrouping and outcome.

Methods

This study was conducted using decompensated cirrhosis (DC) patients hospitalized in the Gastroenterology ward between August 2016 and May 2018. Demographic, clinical, and laboratory parameters were compared between AKI 1A and AKI 1B patients. The duration of hospitalization and outcome were compared.

Results

A total of 528 subjects were enrolled; 296 (56.1%) had AKI, and of them, 61.48% (n = 182) had stage 1, 20.95% (n = 62) had stage 2, and 17.57% (n = 52) had stage 3 AKI. Of the enrolled patients, 100 (54.94%) had early (AKI 1A) and 82 (45.06%) had late stage 1 AKI (AKI 1B). Patients with AKI 1B had higher total leucocyte count, total bilirubin, serum urea, serum creatinine (SCr), model for end‐stage liver disease (MELD), MELD‐Na⁺, and child‐turcotte‐pugh (CTP) score and decreased serum albumin than AKI 1A. The prevalence of hepatorenal syndrome (HRS), acute on chronic liver failure (ACLF) were higher in AKI 1B patients, and they had a prolonged hospital stay compared to AKI 1A patients. Furthermore, AKI 1B patients had significantly lower survival both at 28 days and 90 days.

Conclusion

Our study validates the subclassification of stage 1 AKI. Patients with AKI 1B more often progress to higher AKI stages with significantly lower 28‐day and 90‐day survival rates. Results justify subclassification and suggest the need for early intervention. The small increase in SCr should be viewed with caution in AKI stage 1A.

Acute kidney injury in children with chronic liver disease

Acute kidney injury (AKI) is a common accompaniment in patients with liver disease. The causes, risk factors, manifestations and management of AKI in these patients vary according to the liver disease in question (acute liver failure, acute-on-chronic liver failure, post-liver transplantation or metabolic liver disease). There are multiple causes of AKI in patients with liver disease-pre-renal, acute tubular necrosis, post-renal, drug-induced renal failure and hepatorenal syndrome (HRS). Definitions of AKI in liver failure are periodically revised and updated, but pediatric definitions have still to see the light of the day. As our understanding of the pathophysiology of liver disease and renal involvement improves, treatment modalities have become more advanced and rationalized. Treatment includes reversing precipitating factors, such as infections and gastrointestinal bleeding, volume expansion, paracentesis and vasoconstrictors. This approach is tried and tested in adults. A pediatric tailored approach is still lacking due to inadequate numbers of patients, differences in causes of AKI and paucity of literature. In this review, we attempt to explore the pathophysiological basis, treatment modalities and controversies in the diagnosis and treatment of AKI in pediatric patients with chronic liver disease and discuss our own personal practice. We recognize that, although it is not a very commonly encountered entity in pediatric population, HRS has specific diagnostic criteria and treatment modalities that differ from other causes of AKI in patients with chronic liver disease; hence among the etiologies of kidney injury in patients with chronic liver disease, we focus here on HRS.

RECOMMENDATIONS OF THE BRAZILIAN SOCIETY OF HEPATOLOGY FOR THE MANAGEMENT OF ACUTE KIDNEY INJURY IN PATIENTS WITH CIRRHOSIS

Acute kidney injury is a common complication of cirrhosis, occurring in up to 20% of patients hospitalized with cirrhosis. This field is rapidly changing, with significant advances in classification, biomarkers and therapy over the last few years. On the behalf of the Brazilian Society of Hepatology, a panel of experts in Hepatology and Nephrology reviewed published evidence to integrate findings and develop the recommendations presented in this manuscript.

Mortality from Spontaneous Bacterial Peritonitis Among Hospitalized Patients in the USA

BACKGROUND AND AIM

Spontaneous bacterial peritonitis (SBP) is a serious complication of cirrhosis and is associated with significant morbidity and mortality. In this study, we examined the clinical characteristics and risk factors associated with mortality in hospitalized patients presenting with SBP.

METHODS

The Nationwide Inpatient Sample was queried for all hospitalizations involving SBP from 2006 to 2014 using the International Classification of Disease-9-CM Code. Logistic regression was performed to evaluate the association between SBP mortality and factors such as age, gender, race/ethnicity, and concomitant medical conditions at presentation (e.g., variceal hemorrhage, hepatic encephalopathy, acute renal failure, coagulopathy, and other infections including pneumonia). The lengths of stay (LOS) and total charges were also examined.

RESULTS

From 2006 to 2014, there were 88,167 SBP hospitalizations with 29,963 deaths (17.6% in-hospital mortality). The mean age of patients who died in the hospital was higher (58.2 years vs. 55.8, p < 0.01) than those who survived the admission. Acute alcoholic hepatitis was noted among a higher proportion of patients who died (7.0 vs. 5.9%, p < 0.01), who were also likely to have more medical comorbidities. In multivariable analysis, older age, female gender, hepatic encephalopathy, coagulopathy, variceal hemorrhage, sepsis, pneumonia, and acute kidney injury were associated with increased in-hospital mortality. This group also had longer LOS (11.6 days vs. 9.1, p < 0.01) and higher total charges ($138,273 vs. $73,533, p < 0.01).

CONCLUSION

SBP is associated with significant in-hospital mortality, especially in patients with concurrent risk factors. SBP remains a significant burden to the healthcare system.

Prediction of acute kidney injury in cirrhotic patients: a new score combining renal, liver and inflammatory markers

Introduction

Acute kidney injury (AKI) is common in hospitalized patients with cirrhosis and is associated with poor prognosis. A risk prediction score combining values easily measured at admission could be valuable to stratify patients for prevention, monitoring and early intervention, ultimately improving patient care and outcomes. The aim of this study was to develop a risk score for AKI in a cohort of cirrhotic patients.

Patients and methods

We cross-examined the data from a retrospective analysis of 186 patients with cirrhosis admitted to the Gastroenterology and Hepatology Service of Centro Hospitalar Lisboa Norte from January 2003 to December 2005. AKI was defined as an increase in serum creatinine (SCr)≥0.3 mg/dL within 48 hours or a percentage increase in SCr≥50% from baseline. Neutrophil-to-lymphocyte ratio (NLR) was used as a marker for inflammation. A receiver operating characteristic (ROC) curve was produced to assess the discriminative ability of the variables. Cutoff values were defined as those with highest validity. The final AKI risk score model was assessed using the ROC curve.

Results

A total of 52 patients (28%) developed AKI. Higher baseline SCr (p<0.001), more severe liver disease as evaluated by the modified Model of End-stage Liver Disease (MELD)-Na score (p<0.001) and higher NLR (p=0.028) were independently associated with AKI. The area under the ROC (AUROC) curve for the prediction of AKI was 0.791 (95% CI 0.726–0.847) for SCr, 0.771 (95% CI 0.704–0.829) for modified MELD-Na and 0.757 (95% CI 0.689–0.817) for NLR. Cutoff values with the highest validity for predicting AKI were determined and defined as 0.9 for the SCr, 21.7 for the modified MELD-Na and 6 for the NLR. The risk score was created allowing 3 points if the SCr is higher than 0.9, 1 point if the modified MELD-Na is higher than 21.7 and 1 point if the NLR is higher than 6. The AUROC curve of the risk prediction score for AKI was 0.861. A risk score of ≥2 points predicts AKI in cirrhotic patients with a sensitivity of 88.5% and specificity of 72.4%.

Conclusion

A new score combining SCr, MELD-Na and NLR demonstrated a strong discriminative ability to predict AKI in cirrhotic patients.

Fluctuations of Estimated Glomerular Filtration Rate Outside Kidney Disease Improving Global Outcomes Diagnostic Criteria for Acute Kidney Injury in End-Stage Liver Disease Outpatients and Outcome Postliver Transplantation

BACKGROUND

Renal dysfunction in end-stage liver disease (ESLD) results from systemic conditions that affect both liver and kidney with activation of vasoconstrictor systems. In this setting, estimated glomerular filtration rate (eGFR) may undergo variations often outside Kidney Disease Improving Global Outcomes criteria for acute kidney injury (AKI) diagnosis, whose meaning is not clear. The aim of this study was to evaluate eGFR variations in ESLD outpatients listed for liver transplant (liver Tx) and the association with post-Tx outcome.

METHODS

Fifty-one patients with ESLD were retrospectively evaluated from listing to transplant (L-Tx time), intraoperatively (Tx time), and up to 5 years post-Tx time. Variations between the highest and the lowest eGFR occurring in more than 48 hours, not satisfying Kidney Disease Improving Global Outcomes guideline, were considered as fluctuations (eGFR-F). Fluctuations of eGFR greater than 50% were defined as eGFR drops (DeGFR). Early graft dysfunction, AKI within 7 days, chronic kidney disease, and short- and long-term patient survivals were considered as outcomes.

RESULTS

All patients presented eGFR-F, whereas DeGFR were observed in 18 (35.3%) of 51 (DeGFR+ group). These patients presented higher levels of Model for End-stage Liver Disease score, pre-Tx bilirubin and significantly greater incidence of post-Tx AKI stages 2 to 3 compared with patients without drops (DeGFR-). DeGFR was the only independent predictive factor of the occurrence of post-Tx AKI. The occurrence of AKI post-Tx was associated with the development of chronic kidney disease at 3 months and 5 years post-Tx.

CONCLUSIONS

Drops of eGFR are more frequently observed in patients with a worse degree of ESLD and are associated with a worse post-Tx kidney outcome.

Impact of Acute Kidney Injury on Mortality of Patients Hospitalized for Complications of Cirrhosis

BACKGROUND/AIMS

The mortality of hospitalized patients for complications of cirrhosis is very high. We examined the independent predictors of mortality, particularly the impact of increments in creatinine, in 339 consecutive patients (636 admissions) who were admitted for complications of cirrhosis.

METHODS

Clinical characteristics, biochemical parameters including serum creatinine levels at various time intervals, and mortality data were recorded for all admissions. Data were analyzed for initial as well for all repeated admissions to identify independent predictors of mortality.

RESULTS

The in-hospital mortality, 30-day, 90-day, 180 days, and 365 days mortality were 6%, 15%, 23%, 30%, and 41% respectively. Those admitted with spontaneous bacterial peritonitis had the worst survival. Increase in creatinine was noted in 29% of patients and they had lower 30-day (78% vs.91%) and 90-day (73% vs. 82%) survival than those without increase in creatinine. Any increment in serum creatinine (≥0.1 mg/dL) within 48 h after admission (peak 48 h - admission) was associated with a step-wise increase in mortality, but only if peak creatinine reached above 1.2 mg/dL. If peak creatinine levels were below 1.2 mg/dL, increases in serum creatinine had no impact on survival. Cox regression analysis showed that increments in serum creatinine of 0.3 mg/dL or higher had the worst outcome (HR 2.51, CI 1.65-3.81). Etiology of cirrhosis or the use of PPI, beta blockers or rifaxamin did not predict mortality. Other independent predictors of mortality were age, reason for admission, hyponatremia, and INR.

CONCLUSION

In patients with cirrhosis, any increment in serum creatinine within 48 h from hospitalization is associated with a higher mortality provided the peak serum creatinine within 48 h is above 1.2 mg/dL.

Acute kidney injury in acute-on-chronic liver failure: where does hepatorenal syndrome fit?

Renal dysfunction occurs in 25% to 50% of patients with cirrhosis admitted to the hospital with an acute episode of hepatic decompensation and may be due to underlying chronic kidney disease, an acute deterioration, or both. An acute deterioration in renal function in cirrhotic patients is now collectively referred to as acute kidney injury (AKI), which has been subclassified into different grades of severity that identify prognostic groups. Acute-on-chronic liver failure is characterized by acute hepatic and/or extrahepatic organ failure driven by a dysregulated immune response and systemic inflammatory response. AKI is also one of the defining features of ACLF and a major component in grading the severity of acute-on-chronic liver failure. As such, the pattern of AKI now observed in patients admitted to the hospital with acutely decompensated liver disease is likely to be one of inflammatory kidney injury including acute tubular injury (referred in this review as non-hepatorenal syndrome [HRS]-AKI) rather than HRS. As the management and supportive treatment of non-HRS-AKI potentially differ from those of HRS, then from the nephrology perspective, it is important to distinguish between non-HRS-AKI and HRS-AKI when reviewing patients with acute-on-chronic liver failure and AKI, so that appropriate and early management can be instituted.

Acute Kidney Injury in Cirrhosis: Baseline Serum Creatinine Predicts Patient Outcomes

OBJECTIVES

The International Ascites Club (IAC) recently defined Stage 1 acute kidney injury (AKI) for cirrhosis as an acute increase in serum creatinine (SCr) by ≥0.3 mg/dl or by ≥50% in <48 h from a stable value within 3 months. The baseline SCr may influence AKI risk and patient outcomes. The objective of this study is to determine in cirrhosis whether the baseline SCr has any effect on the in-hospital AKI course and patient survival.

METHODS

North American Consortium for the Study of End-Stage Liver Disease is a consortium of tertiary-care hepatology centers prospectively enroling non-elective cirrhotic inpatients. Patients with different baseline SCr levels (≤0.5, 0.51-1.0, 1.01-1.5, >1.5 mg/dl) were evaluated for the development of AKI, and compared for AKI outcomes and 30-day survival.

RESULTS

653 hospitalized cirrhotics (56.7±10years, 64% men, 30% with infection) were included. The incidence of AKI was 47% of enrolled patients. Patients with higher baseline SCr were more likely to develop AKI, with significantly higher delta and peak SCr (P<0.001) than the other groups, more likely to have a progressive AKI course (P<0.0001), associated with a significantly reduced 30-day survival (P<0.0001). Multivariate logistic regression showed that the delta SCr during an AKI episode to be the strongest factor impacting AKI outcomes and survival (P<0.001), with a delta SCr of 0.70 mg/dl having a 68% sensitivity and 80% specificity for predicting 30-day mortality.

CONCLUSIONS

Admitted cirrhotic patients with higher baseline SCr are at higher risk for in-hospital development of AKI, and more likely to have AKI progression with reduced survival. Therefore, such patients should be closely monitored and treated promptly for their AKI.

Kidney Injury in Liver Disease

Acute kidney injury (AKI) occurs frequently in patients with liver disease and increases morbidity and mortality. Hepatorenal syndrome is a common cause of AKI in patients with decompensated cirrhosis and is due to alterations in systemic and renal hemodynamics. Serum creatinine-based estimation of kidney function is a key component of the Model for End-stage Liver Disease score in liver transplant candidates. Continuous renal replacement therapy is used in critically ill patients with liver failure and AKI. Simultaneous liver-kidney transplantation (SLK) may be required in patients with liver failure and prolonged AKI. Identification of appropriate candidates for SLK remains controversial.

Clinical Outcomes of Peritoneal Dialysis in End-Stage Renal Disease Patients with Liver Cirrhosis: A Propensity Score Matching Study

Background

Clinical results of long-term peritoneal dialysis (PD) therapy in patients with liver cirrhosis (LC) and end-stage renal disease (ESRD) are controversial. This study evaluated the clinical outcomes of LC patients undergoing PD.

Methods

Clinical records were retrospectively collected from a single center between January 2007 and December 2014. An analysis of PD patients with LC and without liver disease was performed using propensity score matching. We further restricted matching by age, gender, and the presence of diabetes mellitus. Two cohorts of 33 patients each were selected. Early technical complications were defined as the presence of catheter-related complications, including malposition, leakage, omental wrapping, obstruction, and requiring a transfer to hemodialysis (HD) within 6 months of initiating PD.

Results

Mean PD duration was lower in LC patients (57.2 ± 46.1 months) than in controls (85.8 ± 64.2 months). Blood urea nitrogen, creatinine, and albumin levels were significantly lower in LC patients than in the control group. Cystatin C and cystatin C-based glomerular filtration rates were not significantly different in the LC group compared with those in the controls. We found that the risks for early technical complications, peritonitis, and long-term PD and patient survival were not higher in patients with LC than in those without LC. Ascites were easily controlled, and hepatic encephalopathy did not affect PD maintenance in LC patients.

Conclusions

The clinical outcomes, including technical complications, peritonitis, and patients’ survival, suggest that PD can be used as a renal replacement therapy in ESRD patients with LC.

Validation of a Staging System for Acute Kidney Injury in Patients With Cirrhosis and Association With Acute-on-Chronic Liver Failure

BACKGROUND & AIMS

In patients with cirrhosis of the liver, acute kidney injury (AKI) is classified into 3 stages. Recent studies indicate that there are 2 subgroups of stage 1 disease, associated with different outcomes and serum levels of creatinine (SCr): stage 1A (SCr <1.5 mg/dL) and stage 1B (SCr ≥1.5 mg/dL). We performed a prospective study to validate, in a large series of patients with cirrhosis, the association between this new description and patient outcomes, and assess the relationship between AKI stage and the presence of acute-on-chronic liver failure.

METHODS

We collected data from 547 consecutive patients admitted for cirrhosis with acute decompensation to 2 tertiary hospitals (Italy and Spain), from February 2011 through June 2015. A total of 290 patients had AKI (53%; 197 had stage 1 disease); AKI stages were determined based on levels of SCr at diagnosis. Patients were followed up until death, liver transplantation, or for 90 days. The primary outcome was 90-day survival; secondary outcomes were progression and resolution of AKI and association with acute-on-chronic liver failure.

RESULTS

Based on level of sCr at diagnosis, 58 patients had stage 1A disease and 139 had stage 1B disease. Of patients with stage 1A disease, 82% survived for 90 days; of patients with stage 1B disease, 55% survived for 90 days (P = .001). Hepatorenal syndrome and acute tubular necrosis were the most common causes of stage 1B AKI, and hypovolemia was the most common cause of stage 1A AKI. AKI progressed in a higher proportion of patients with 1B than 1A AKI (31% vs 15%; P = .017) and resolved in a higher proportion of patients with 1A disease (90% vs 52% of patients with stage 1B; P < .001). Stage 1B disease, but not 1A, was an independent predictor of AKI progression and mortality. ACLF developed in a significantly greater proportion of patients with stage 1B disease (76%) than stage 1A disease (22%; P < .001), which could account for the poor outcomes of patients with stage 1B disease.

CONCLUSIONS

In a large group of patients with decompensated cirrhosis, we validated the association between AKI stages IA and IB (based on level of sCR) with survival times and AKI progression. We also associated these subgroups of AKI with development of acute-on-chronic liver failure. These findings are important for management of patients with decompensated cirrhosis.

Acute kidney injury in liver cirrhosis: new definition and application

The traditional diagnostic criteria of renal dysfunction in cirrhosis are a 50% increase in serum creatinine (SCr) with a final value above 1.5 mg/dL. This means that patients with milder degrees of renal dysfunction are not being diagnosed, and therefore not offered timely treatment. The International Ascites Club in 2015 adapted the term acute kidney injury (AKI) to represent acute renal dysfunction in cirrhosis, and defined it by an increase in SCr of 0.3 mg/dL (26.4 µmoL/L) in <48 hours, or a 50% increase in SCr from a baseline within ≤3 months. The severity of AKI is described by stages, with stage 1 represented by these minimal changes, while stages 2 and 3 AKI by 2-fold and 3-fold increases in SCr respectively. Hepatorenal syndrome (HRS), renamed AKI-HRS, is defined by stage 2 or 3 AKI that fulfils all other diagnostic criteria of HRS. Various studies in the past few years have indicated that these new diagnostic criteria are valid in the prediction of prognosis for patients with cirrhosis and AKI. The future in AKI diagnosis may include further refinements such as inclusion of biomarkers that can identify susceptibility for AKI, differentiating the various prototypes of AKI, or track its progression.

Protecting the Kidney in Liver Transplant Candidates: Practice-Based Recommendations From the American Society of Transplantation Liver and Intestine Community of Practice

Acute kidney injury (AKI) and chronic kidney disease (CKD) are common in patients awaiting liver transplantation, and both have a marked impact on the perioperative and long-term morbidity and mortality of liver transplant recipients. Consequently, we reviewed the epidemiology of AKI and CKD in patients with end-stage liver disease, highlighted strategies to prevent and manage AKI, evaluated the changing liver transplant waiting list's impact on kidney function, delineated important considerations in simultaneous liver-kidney transplant selection, and projected possible future transplant policy changes and outcomes. This review was assembled by experts in the field and endorsed by the American Society of Transplantation Liver and Intestinal Community of Practice and Board of Directors and provides practice-based recommendations for preservation of kidney function in patients with end-stage liver disease.

Predictors of fifty days in-hospital mortality in decompensated cirrhosis patients with spontaneous bacterial peritonitis

AIM

To determine the predictors of 50 d in-hospital mortality in decompensated cirrhosis patients with spontaneous bacterial peritonitis (SBP).

METHODS

Two hundred and eighteen patients admitted to an intensive care unit in a tertiary care hospital between June 2013 and June 2014 with the diagnosis of SBP (during hospitalization) and cirrhosis were retrospectively analysed. SBP was diagnosed by abdominal paracentesis in the presence of polymorphonuclear cell count ≥ 250 cells/mm(3) in the peritoneal fluid. Student's t test, multivariate logistic regression, cox proportional hazard ratio (HR), receiver operating characteristics (ROC) curves and Kaplan-Meier survival analysis were utilized for statistical analysis. Predictive abilities of several variables identified by multivariate analysis were compared using the area under ROC curve. P < 0.05 were considered statistical significant.

RESULTS

The 50 d in-hospital mortality rate attributable to SBP is 43.11% (n = 94). Median survival duration for those who died was 9 d. In univariate analysis acute kidney injury (AKI), hepatic encephalopathy, septic shock, serum bilirubin, international normalized ratio, aspartate transaminase, and model for end-stage liver disease - sodium (MELD-Na) were significantly associated with in - hospital mortality in patients with SBP (P ≤ 0.001). Multivariate cox proportional regression analysis showed AKI (HR = 2.16, 95%CI: 1.36-3.42, P = 0.001) septic shock (HR = 1.73, 95%CI: 1.05-2.83, P = 0.029) MELD-Na (HR = 1.06, 95%CI: 1.02-1.09, P ≤ 0.001) was significantly associated with 50 d in-hospital mortality. The prognostic accuracy for AKI, MELD-Na and septic shock was 77%, 74% and 71% respectively associated with 50 d in-hospital mortality in SBP patients.

CONCLUSION

AKI, MELD-Na and septic shock were predictors of 50 d in-hospital mortality in decompensated cirrhosis patients with SBP.

Evaluation of acute kidney injury and its response to terlipressin in patients with acute-on-chronic liver failure

BACKGROUND & AIMS

Patients with acute-on-chronic liver failure (ACLF) have high mortality. Cirrhotics with acute kidney injury (AKI) have poor outcome but relevance of AKI and response to terlipressin in ACLF is not known.

METHODS

Consecutive ACLF patients with AKI at admission were compared with those without AKI (controls) for mortality at day 7, month 1 and 3, presence of hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP) and acute variceal bleed (AVB). Patients were also compared based on severity of AKI (mild; S.cr 1.5-3 mg/dl and marked; S.cr >3 mg/dl). Response to terlipressin was also evaluated.

RESULTS

Of 241 ACLF patients, 55 (22.8%) had AKI at admission. Patients with AKI had higher mortality at day 7, 1 and 3 month and more often developed HE [54.1% vs. 30.6%; P = 0.001] and SBP [9.1% vs. 5.9%; P = 0.02]. Patients with marked AKI neither had higher mortality or complications in comparison to mild AKI. Presence of AKI [Odds ratio; OR, 2.4], S.bilirubin >20 mg/dl [OR, 3.1] and INR [OR, 2.9] were independent baseline predictors of mortality. Terlipressin was used in 28 of 55 patients with AKI who were volume non-responsive (hepatorenal syndrome, AKI-HRS). Ten (35.7%) of these showed response (S.Cr < 1.5 mg/dl) [median 4 days] and had lower mortality compared to terlipressin non-responders (10% vs. 50%, P = 0.05). There was no difference in terlipressin response in mild vs. marked AKI.

CONCLUSIONS

Almost one-fourth of the ACLF patients have AKI at admission and presence of AKI, but not its severity predicts complications and high mortality. Terlipressin effectively reverses AKI-HRS within a week in ~35% of ACLF patients resulting in improved survival.

Acute-on-Chronic Liver Failure

Over the past 2 decades, the concept of acute-on-chronic liver failure (ACLF) has been proposed as an alternate path in the natural history of decompensated cirrhosis. ACLF thus is characterized by the presence of a precipitating event (identified or unidentified) in subjects with underlying chronic liver disease leading to rapid progression of liver injury and ending in multi-organ dysfunction characterized by high short-term mortality. Multiple organ failure and an increased risk for mortality are key to the diagnosis of ACLF. The prevalence of ACLF ranges from 24% to 40% in hospitalized patients. The pathophysiological basis of ACLF can be explained using the following 4-part model: predisposing event, injury caused by a precipitating event, response to injury, and organ failure. Although several mathematic scores have been proposed for identifying outcomes with ACLF, it is as yet unclear whether these organ failure scores are truly prognostic or only reflective of the dying process. Treatment paradigms continue to evolve but consist of early recognition, supportive intensive care, and consideration of liver transplantation before onset of irreversible multiple organ failure.

Pathogenesis of Hepatorenal Syndrome: Implications for Therapy

Patients with cirrhosis are prone to develop acute kidney injury (AKI) due to a number of causes, including bacterial infections with or without septic shock, hypovolemia, administration of nephrotoxic drugs, and intrinsic kidney diseases, among others. Most importantly, patients with advanced cirrhosis develop a distinctive cause of AKI, characterized by rapidly progressive glomerular filtration rate loss associated with marked disturbances in circulatory function in the absence of obvious pathologic abnormalities in the kidneys, known as hepatorenal syndrome (HRS). Decreased kidney function results from intense renal vasoconstriction secondary to the complex circulatory changes of cirrhosis with splanchnic vasodilatation and effective hypovolemia. Beyond activation of vasoactive systems, factors including impaired renal blood flow autoregulation and systemic inflammation may play a role in the development of HRS. Most patients improve with albumin and vasopressors; however, the prognosis of HRS remains very poor. Novel biomarkers may be helpful in distinguishing HRS from other causes of AKI in patients with cirrhosis.