Outcome and features of acute kidney injury complicating hypoxic hepatitis at the medical intensive care unit

Abstract

BackgroundHypoxic hepatitis (HH) is a frequent and potentially life-threatening event typically occurring in critically ill patients as a consequence of hemodynamic impairment. While acute kidney injury (AKI) has been well described in patients with acute liver failure, incidence and outcome of AKI accompanying HH are unclear. The aim of this study was to assess incidence, clinical implications and outcome of AKI and renal replacement therapy (RRT) in critically ill patients with HH.MethodsA total of 1948 consecutive critically ill admissions were studied at the Medical University of Vienna. Laboratory and clinical parameters as well as the presence of HH and AKI were assessed on a daily basis. Outcome, renal recovery and length of stay were assessed and documented, and patients were followed for 1 year.ResultsA total of 295 admissions (15 %) developed HH. Main precipitators were cardiogenic (44 %) and septic shock (36 %). Occurrence of HH was significantly associated with AKI [OR 4.50 (95 % CI 3.30–6.12)] and necessity of renal replacement therapy [RRT; OR 3.36 (95 % CI 2.58–4.37)], p < 0.001 for both. Two hundred forty admissions with HH (81 %) developed AKI, 159 of whom (66 %) had AKI stage 3. Both HH and AKI were significantly linked to mortality. AKI stage 3, international normalized ratio (INR, during HH) and the presence of septic shock were identified as independent predictors of 28-day mortality in admissions with HH, whereas RRT was identified as an independent protective factor. There was a synergistic effect of HH and AKI on length of stay at the ICU. Of all HH survivors treated with RRT, 71 % showed renal recovery during follow-up.ConclusionHH is frequently complicated by occurrence of AKI. Severity of HH, AKI stage and the presence of septic shock seem to contribute to poor outcome in these patients. Initiation of RRT in HH with AKI may enable renal recovery and should not be withheld in medical ICU patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-016-0162-4) contains supplementary material, which is available to authorized users.

Ischemic Hepatitis – Intercorrelated Pathology

“…Most cardiologists chose to stop the treatment in these particular situations. A recent study on 851 patients admitted to ICU, of which 87 presented IH/HH, showed that IH/HH had developed in 11% of those without statin therapy vs. 5% of subjects on statins at admission (26). These results need further validation in future studies.…”

“…In a recent study on 240 patients with IH/HH, 81% developed AKI, more than with half stage 3 AKI. In IH/HH patients, AKI correlated with underlying disease severity, especially shock, vasoactive drugs and elevated lactate level on admission (26).…”

Liver Injury and Failure in Critical Illness

“…Although hyperammonemia is frequently observed in patients with HLI, the impact of ammonia‐lowering measures has not been assessed in this patient population so far. Initiation of RRT improved 28‐day survival in a large observational analysis of patients with HLI . Although mortality was high in patients with HLI and RRT, kidney function recovered in 71% of the ICU‐surviving patients with 1‐year survival rates of approximately 60%.…”

“…HLI is by far the most common cause of massive elevated aminotransferase levels in hospitalized patients . The prevalence of HLI ranges between 1% and 12% in ICU and may be even higher in patients with cardiogenic shock, in whom the prevalence was reported to be greater than 20% …”

“…Vasopressor therapy is necessary in 50%‐85%. Furthermore, 70%‐80% of the patients require mechanical ventilation, and renal replacement therapy (RRT) is performed in up to 41% . More than 80% of the patients develop HLI within the first 24 hours after ICU admission.…”