Impact of Chronic Kidney Disease on Outcomes in Cirrhosis

Abstract

We hypothesize that the prevalence of chronic kidney disease (CKD) among patients with cirrhosis has increased due to the increased prevalence of CKD‐associated comorbidities, such as diabetes. We aimed to assess the characteristics of hospitalized patients with cirrhosis with CKD and its impact on renal and patient outcomes. The North American Consortium for the Study of End‐Stage Liver Disease (NACSELD) prospectively enrolled nonelectively admitted patients with cirrhosis and collected data on demographics, laboratory results, in‐hospital clinical course, and postdischarge 3‐month outcomes. CKD positive (CKD+) patients, defined as having an estimated glomerular filtration rate (eGFR; Modification of Diet in Renal Disease–4 variable formula) of ≤60 mL/minute for >3 months, were compared with chronic kidney disease negative (CKD–) patients for development of organ failures, hospital course, and survival. There were 1099 CKD+ patients (46.8% of 2346 enrolled patients) who had significantly higher serum creatinine (2.21 ± 1.33 versus 0.83 ± 0.21 mg/dL in the CKD– group) on admission, higher prevalence of nonalcoholic steatohepatitis cirrhosis etiology, diabetes, refractory ascites, and hospital admissions in the previous 6 months compared with the CKD– group (all P < 0.001). Propensity matching (n = 922 in each group) by Child‐Pugh scores (9.78 ± 2.05 versus 9.74 ± 2.04, P = 0.70) showed that CKD+ patients had significantly higher rates of superimposed acute kidney injury (AKI; 68% versus 21%; P < 0.001) and eventual need for dialysis (11% versus 2%; P < 0.001) than CKD– patients. CKD+ patients also had more cases of acute‐on‐chronic liver failure as defined by the NACSELD group, which was associated with reduced 30‐ and 90‐day overall survival (P < 0.001 for both). A 10 mL/minute drop in eGFR was associated with a 13.1% increase in the risk of 30‐day mortality. In conclusion, patients with CKD should be treated as a high‐risk group among hospitalized patients with cirrhosis due to their poor survival, and they should be monitored carefully for the development of superimposed AKI.

Chronic Kidney Disease in Liver Transplant Candidates: A Rising Burden Impacting Post–Liver Transplant Outcomes

“…They are therefore more susceptible to episodes of AKI and are less likely to have the renal reserve to recover from these episodes. This is supported by previous studies that demonstrated that those with a higher baseline creatinine are more susceptible to AKI and less likely to recover from those episodes of AKI . Second, this increased susceptibility is potentiated by factors that lead to longer wait times, whereby patients who spend more time at risk for renal injury are most vulnerable to CKD.…”

“…However, use of SLKT is highly variable, so this may not be the best metric to describe changes in the prevalence of CKD . This is critical because it is becoming more evident that pre‐LT CKD impacts the risk of both pre‐LT AKI and wait‐list mortality . That being said, although studies have investigated the impact of pre‐LT renal function on post‐LT survival, these studies were limited by subjective definitions of renal failure that did not distinguish between AKI and CKD .…”

“…(2,6,7) This is critical because it is becoming more evident that pre-LT CKD impacts the risk of both pre-LT AKI and wait-list mortality. (8,9) That being said, although studies have investigated the impact of pre-LT renal function on post-LT survival, these studies were limited by subjective definitions of renal failure that did not distinguish between AKI and CKD. (10)(11)(12) Consequently, cullarO et al Abbreviations Original article | 499 it is not established if pre-LT renal function patterns differentially impact post-LT outcomes.…”

Chronic Kidney Disease in Cirrhosis: Emerging Complication With Negative Impact in the Liver Transplant Setting

“…As compared with patients without CKD, those with CKD were older and had significantly higher frequency of NASH‐related cirrhosis and diabetes mellitus. These results are in keeping with those from a recent study indicating that CKD in cirrhosis is common and that NASH as the etiology of cirrhosis with accompanying diabetes mellitus are risk factors to the development of CKD …”

“…Recent studies in hospitalized patients with cirrhosis indicate that chronic kidney disease (CKD) is common in this population, ranging from 20% to 46%. This is explained, at least in part, by the increase in the prevalence of nonalcoholic steatohepatitis (NASH)–related cirrhosis and associated comorbidities, such as diabetes mellitus and arterial hypertension . However, information on the burden of CKD in patients with cirrhosis is still limited.…”