Prognosis of Patients with Cirrhosis and AKI Who Initiate RRT

Abstract

Background and objectivesLiterature 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, & measurementsRetrospective 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.ResultsFour 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).ConclusionsCause 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.PodcastThis article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_11_09_CJASNPodcast_18_1_A.mp3

Development of chronic kidney disease after acute kidney injury in patients with cirrhosis is common and impairs clinical outcomes

“…5,6 The concept of AKI has been a major step forward in the diagnosis of acute impairment of kidney function in clinical practice and has stimulated research in this field. Some important new concepts have emerged from the research on AKI in cirrhosis in recent years, including; i) staging of patients with AKI in 4 different categories (1A, 1B, 2, and 3) that correlates with clinical outcomes; 6,7 ii) relevance of baseline serum creatinine in the prediction of outcomes; 8,9 iii) relevance of urinary output as an important prognostic factor in patients with AKI; 10 iv) outcome of renal replacement therapy in patients with AKI; 11 and v) identification of some kidney biomarkers able to establish with high accuracy the differential diagnosis between hepatorenal syndrome (currently known as HRS-AKI) and acute tubular necrosis (ATN). [12][13][14][15] Despite this important progress, some relevant questions related to AKI in cirrhosis still remain unanswered.…”

Controversies Surrounding Renal Replacement Therapy in the Critically Ill Patient

“…69 This was demonstrated by Allegretti et al who showed an 84% mortality at 6 months, with a mean survival of 21 days for patients, not listed for liver transplant, who developed hepatorenal syndrome and were started on dialysis. 70 Nephrologists should openly communicate to the patient and/or family if they feel RRT would be medically unbeneficial.…”

Renal Function in Cirrhosis: A Critical Review of Available Tools

“…50 It is worth noting that recent data showed a very poor prognosis in patients with cirrhosis and AKI not eligible for liver transplantation treated with RRT, regardless the indication was ATN-AKI or HRS-AKI (85% mortality at 6 months), thus, it may be futile in these patients. 89 Extracorporeal liver support systems have been used in the treatment of patients with ACLF (including those with HRS-AKI). The aim of these systems is to remove toxins such as bilirubin, bile acids, aromatic amino acids, and cytokines using an albumin dialysis-based technique.…”