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

A dynamic model to predict early occurrence of acute kidney injury in ICU hospitalized cirrhotic patients: a MIMIC database analysis

BACKGROUND

This study aimed to develop a tool for predicting the early occurrence of acute kidney injury (AKI) in ICU hospitalized cirrhotic patients.

METHODS

Eligible patients with cirrhosis were identified from the Medical Information Mart for Intensive Care database. Demographic data, laboratory examinations, and interventions were obtained. After splitting the population into training and validation cohorts, the least absolute shrinkage and selection operator regression model was used to select factors and construct the dynamic online nomogram. Calibration and discrimination were used to assess nomogram performance, and clinical utility was evaluated by decision curve analysis (DCA).

RESULTS

A total of 1254 patients were included in the analysis, and 745 developed AKI. The mean arterial pressure, white blood cell count, total bilirubin level, Glasgow Coma Score, creatinine, heart rate, platelet count and albumin level were identified as predictors of AKI. The developed model had a good ability to differentiate AKI from non-AKI, with AUCs of 0.797 and 0.750 in the training and validation cohorts, respectively. Moreover, the nomogram model showed good calibration. DCA showed that the nomogram had a superior overall net benefit within wide and practical ranges of threshold probabilities.

CONCLUSIONS

The dynamic online nomogram can be an easy-to-use tool for predicting the early occurrence of AKI in critically ill patients with cirrhosis.

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.

Outcomes of Upper Gastrointestinal Bleeding in Hospitalized COVID-19 Patients in the United States: A Propensity-score Matched Analysis of a Large National Database

Patients with cirrhosis that are hospitalized with COVID-19 infection have been found to have worse outcomes. No comparative study has been conducted between gastrointestinal (GI) bleeding in patients with cirrhosis who are diagnosed with COVID-19. We utilized the National Inpatient Sample (NIS) database to perform a retrospective analysis of 24, 050 patients diagnosed with cirrhosis and COVID-19. The identified patients were separated into variceal bleeding, nonvariceal bleeding, and no (or neither) GI bleeding groups. After performing propensity sample matching and multivariate analysis of mortality, we found no significant differences in mortality among the three groups. However, the variceal bleed group had a shorter length of stay (5.67 days lower than the no-bleed group). Esophagogastroduodenoscopy (EGD) with intervention was associated with reduced mortality in the variceal and nonvariceal bleeding groups. Acute kidney injury was a strong predictor of mortality in both bleeding groups. A native American race was found to be associated with higher mortality in the nonvariceal bleeding group. Our study suggests that there are various pathophysiological processes among the three groups, with no significant mortality differences with cirrhosis complications of GI bleeding.

Etiological Spectrum of Cirrhosis in India: A Systematic Review and Meta-analysis

BACKGROUND

Cirrhosis is a significant cause of morbidity and mortality globally and in India. This systematic review and meta-analysis aimed to ascertain the etiological spectrum and changing trends of cirrhosis in India.

METHODS

We searched electronic databases, including Pubmed/Medline, Scopus, and Embase. We included original studies that reported the etiology of cirrhosis in the Indian population.

RESULTS

We included 158 studies (adults: 147, children: 11). The overall pooled estimate of alcohol as a cause of cirrhosis in adults was 43.2% (95% confidence interval (CI) 39.8-46.6%; I2 = 97.8%), followed by nonalcoholic fatty liver disease (NAFLD)/cryptogenic in 14.4%, 95% CI (11.7-17.3%; I2 = 98.4%), hepatitis B virus (HBV) in 11.5%, 95% CI (9.8-13.3%; I2 = 96.6%), and hepatitis C virus (HCV) in 6.2%, 95% CI (4.8-7.8%; I2 = 97.2%) of the included patients. The most common cause of cirrhosis in all zones was alcohol-related. Comparison of etiologies over time revealed a reduction in the viral hepatitis-related and an increase in the proportion of alcohol-related and NAFLD/cryptogenic-related cirrhosis. The overall pooled estimates of various etiologies in children were: HBV in 10.7%, 95% CI (4.6-18.7%; I2 = 91.0%), NAFLD/Cryptogenic in 22.3%, 95% CI (9.0-39.2%; I2 = 96.7%), and HCV in 2.0%, 95% CI (0.0-8.5%; I2 = 94.6%).

CONCLUSIONS

Alcohol is the most common etiology of cirrhosis in adults in India. The proportions of alcohol and NAFLD-related cirrhosis are increasing, and those of viral hepatitis-related cirrhosis are reducing. The results of our meta-analysis will help formulate health policies and the allocation of resources.

Predictors of Acute Kidney Injury in Patients Hospitalized With Liver Cirrhosis: A Systematic Review and Meta-Analysis

Acute kidney injury (AKI) frequently occurs in hospitalized individuals with liver cirrhosis and represents a significant risk factor for early in-hospital mortality, holding crucial clinical and prognostic importance. The objective of this meta-analysis was to assess the risk factors associated with AKI in hospitalized individuals with cirrhosis. This systematic review and meta-analysis was conducted in concordance with guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Two independent researchers systematically searched major databases, including MEDLINE/PubMed, Web of Science, and EMBASE, from January 2015 until December 2023. A total of 14 studies were included in this meta-analysis, of which six were prospective, and the remaining were retrospective. Of the 9,659 cirrhosis patients in the 14 included studies, 3,968 had developed AKI with a pooled incidence of 41% (95% confidence interval = 34-47%). Our findings showed that a high Model for End-Stage Liver Disease (MELD) score, infection, high Child-Pugh-Turcotte stage score, high serum creatinine, high serum bilirubin, and low serum albumin were significantly associated with high incidence of AKI in liver cirrhosis patients. The results emphasize the importance of vigilant monitoring in cirrhosis patients to detect any indications of AKI, followed by meticulous and attentive management.

Acute Kidney Injury in Liver Cirrhosis

Acute kidney injury (AKI) is common in cirrhotic patients affecting almost 20% of these patients. While multiple etiologies can lead to AKI, pre-renal azotemia seems to be the most common cause of AKI. Irrespective of the cause, AKI is associated with worse survival with the poorest outcomes observed in those with hepatorenal syndrome (HRS) and acute tubular necrosis (ATN). In recent years, new definitions, and classifications of AKI in cirrhosis have emerged. More knowledge has also become available regarding the benefits and drawbacks of albumin and terlipressin use in these patients. Diagnostic tools such as urinary biomarkers and point-of-care ultrasound (POCUS) became available and they will be used in the near future to differentiate between different causes of AKI and direct management of AKI in these patients. In this update, we will review these new classifications, treatment recommendations, and diagnostic tools for AKI in cirrhotic patients.

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.

Retrospective analyses of the outcomes among hospitalized liver cirrhosis patients with heart failure and COVID-19 infection: Insight from the National Inpatient Sample

Background

There is paucity of data regarding the impact of Coronavirus Disease 2019 (COVID-19) infection on the outcomes of hospitalized liver cirrhosis (LC) patients with heart failure (HF).

Methods

Utilizing the 2020 National Inpatient Sample (NIS) Database, we conducted a retrospective cohort study to investigate the outcomes of hospitalized LC patients with HF and COVID-19 infection, looking at its impact on in-hospital mortality, risk for acute kidney injury (AKI) and length of stay (LOS).

Results

We identified a total of 10,810 hospitalized LC patients with HF, of which 1.39 % (n = 150/10,810) had COVID-19 infection. Using a stepwise survey multivariable logistic regression model that adjusted for patient and hospital level confounders, COVID-19 infection among hospitalized LC patients with HF was found to be an independent predictor of overall in-hospital mortality (aOR 3.73; 95 % CI, 1.58-8.79; p = 0.00) and risk for AKI (aOR 3.06; 95 % CI, 1.27-7.37; p = 0.01) compared to those without COVID-19 infection. However, there were comparable rates of LOS among LC patients with HF regardless of COVID-19 infection status. Moreover, AKI was found to be an independent predictor of longer LOS (coefficient 4.40, 95 % CI 3.26-5.38; p = 0.00). On subgroup analysis, diastolic HF was found to be associated with increased risk for in-hospital mortality (aOR 6.54; 95 % CI, 2.02-21.20; p = 0.00), development of AKI (aOR 3.33; 95 % CI, 1.12-9.91; p = 0.03) and longer LOS (coefficient 4.30, 95 % CI 0.79-9.45; p = 0.03).

Conclusion

Concomitant COVID-19 infection among hospitalized LC patients with HF was associated with higher risk for in-hospital mortality and AKI but did not significantly affect hospital LOS.

Acute Kidney Injury (AKI) at Admission Predicts Mortality in Patients With Severe Alcoholic Hepatitis (SAH)

Background & aims

Severe alcoholic hepatitis (SAH) is a grave condition, and the presence of acute kidney injury (AKI) further jeopardizes patient survival. However, the impact of AKI on survival in SAH has not been assessed from this region of Asia.

Materials and methods

This study was conducted on consecutive alcohol-associated liver disease (ALD) patients hospitalized in Gastroenterology Department, SCB Medical College, Cuttack, India, between October 2016 and December 2018. On diagnosis of SAH (mDF score ≥32), demographic, clinical, and laboratory parameters were recorded, and survival was compared between patients with and without AKI (AKIN criteria). In addition, survival was compared among SAH patients defined by other criteria and prognostic models in the presence and absence of AKI.

Results

309 (70.71%) of ALD patients had SAH, and 201 (65%) of them had AKI. SAH patients with AKI had higher total leucocyte count, total bilirubin, serum creatinine, serum urea, INR, MELD (UNOS), MELD (Na+), CTP score, mDF score, Glasgow score, ABIC score, and increased prevalence of acute on chronic liver failure (ACLF) as per EASL-CLIF Consortium criteria (P < 0.001). Further, they had prolonged hospital stay, and increased death during hospitalization, at 28 days as well as 90 days (P < 0.001). Significant differences in survival were also seen in SAH (as per MELD, ABIC, and GAHS criteria) patients above the marked cut offs in respect to AKI.

Conclusions

Over two-thirds of ALD patients had SAH, and about two-thirds had AKI. Patients with SAH and AKI had an increased prevalence of ACLF, longer hospital stay, and increased mortality during hospitalization at 28 days and 90 days.

Lay summary

SAH is a critical condition, and the presence of AKI negatively affects their survival. Hence, early identification of SAH and AKI, as well as early initiation of treatment, is crucial for better survival. Our study from the coastal part of eastern India is the first to demonstrate the prevalence of SAH among patients with ALD along with the prevalence of AKI among SAH patients in this region. This knowledge will be helpful in managing these patients from this region of world.

Development and validation of a nomogram for predicting overall survival in cirrhotic patients with acute kidney injury

BACKGROUND

Acute kidney injury (AKI) is a common and severe complication in patients with cirrhosis, and is associated with poor prognosis. Therefore, identifying cirrhotic patients with AKI who are at high risk of mortality is very important and may be helpful for providing timely medical interventions to improve the prognosis of these patients. However, studies focused on investigating the risk factors for the mortality of cirrhotic patients with AKI were scarce.

AIM

To identify risk factors for mortality and establish a nomogram for predicting the prognosis of these patients.

METHODS

Two hundred fifty consecutive patients with cirrhosis and AKI were recruited and randomly divided into training cohort (n = 173) and validation cohort (n = 77). In the training cohort, potential risk factors for death were identified by performing a Cox regression analysis, and a nomogram was established. The predictive performance of the nomogram was internally and externally validated by calculating the area under the receiver operating characteristic curve (AUROC), constructing a calibration curve and performing decision curve analysis.

RESULTS

The serum sodium level, international normalized ratio, peak serum creatinine level > 1.5 mg/dL, the presence of hepatic encephalopathy and diabetes were potential risk factors for mortality of cirrhotic patients with AKI in the training dataset. A prognostic nomogram incorporating these variables was established for predicting the overall survival of these patients. Compared with Child-Turcotte-Pugh, the model for end-stage liver disease (MELD) and the MELD-Na scores, the nomogram in predicting 90- and 180-d mortality exhibited better discriminatory power with AUROCs of 0.792 and 0.801 for the training dataset and 0.817 and 0.862 for the validation dataset, respectively. With a nomogram score of 98, patients were divided into low- and high-risk groups, and high-risk patients had a higher mortality rate.

CONCLUSION

A prognostic nomogram displayed good performance for predicting the overall survival of cirrhotic patients with AKI, and will assist clinicians in evaluating the prognosis of these patients.

Value of Acute Kidney Injury in Predicting Mortality in Vietnamese Patients with Decompensated Cirrhosis

Background: Acute kidney injury remains a common complication with a poor prognosis, and is a significant predictor of mortality in cirrhosis patients. We aimed to determine the percentage of acute kidney injury in decompensated cirrhosis patients and evaluate the treatment results of acute kidney injury as well as several factors related to the mortality of decompensated cirrhosis patients. Methods: A prospective study was conducted on decompensated cirrhosis patients in Can Tho City, Vietnam, from 2019 to 2020. Decompensated cirrhosis patients were found to have acute kidney injury on admission by a blood creatinine test. They were treated according to ICA 2015 standards, after which they were monitored and evaluated for treatment outcomes during hospitalization. Results: Of 250 decompensated cirrhosis patients, 64 (25.6%) had acute kidney injury and 37.5% died. Several factors were associated with mortality in decompensated cirrhosis patients, such as Child–Pugh C (p = 0.02; OR = 3, 95% CI 1.5–6.3), acute kidney injury (p < 0.0001; OR = 9.5, 95% CI 4.3–21.1), hyponatremia (p = 0.01; OR = 2.5, 95% CI 1.2–5.1), elevated total bilirubin > 51 µmol/L (p = 0.03; OR = 2.2, 95% CI 1.1–4.6), and prothrombin < 70% (p = 0.03; OR = 6.8, 95% CI 1–51.6). Hypoalbuminemia was unrelated to mortality in these patients (p = 0.8; OR = 1.2, 95% CI 0.5–2.7), but gastrointestinal bleeding significantly increased mortality in these patients up to 2.3 times (p = 0.03; OR = 2.3, 95% CI 1.1–4.9). Three independent factors regarding mortality in decompensated cirrhosis patients included acute kidney injury, hepatic encephalopathy, and gastrointestinal bleeding. The rate of acute kidney injury in patients with decompensated cirrhosis was 25.6%; the mortality rate was 37.5%. Conclusions: Acute kidney injury was a valuable predictor of mortality in Vietnamese patients with decompensated cirrhosis.

Risk and protective factors of acute kidney injury in decompensated cirrhotic patients with ascites on tolvaptan

Background and Aim

Acute kidney injury (AKI) is a life‐threatening complication of liver cirrhosis. Here, we evaluated the risk factors and characteristics of AKI in cirrhosis.

Patients/Methods

This was a single‐center retrospective study. A total of 199 Japanese patients with decompensated liver cirrhosis (104 men, median age 61 years) were enrolled and received tolvaptan orally. Survival rates and new onset of AKI were monitored, and risk factors were evaluated.

Results

Forty‐six patients (23.1%) suffered an AKI complication and exhibited significantly poorer survival (P < 0.01). The rates of hepatic encephalopathy (P < 0.01) and chronic kidney disease (CKD; P = 0.02) were significantly increased in patients with AKI. The rate of proton pump inhibitor (PPI)/H2 blocker treatment (P = 0.04) was significantly lower, whereas that of ascites drainage was significantly higher in the AKI cases (P < 0.01). The AKI risk was significantly increased in patients with hepatic encephalopathy (HR 4.18, 95% CI 1.618–10.771). In contrast, the incidence of AKI was significantly lower in patients with a higher serum albumin level (HR 0.36, 95% CI 0.142–0.914, P = 0.03). Treatment with PPI/H2 blockers (HR 0.30, 95% CI 0.126–0.711, P < 0.01) or kanamycin/rifaximin (HR 0.26, 95% CI 0.075–0.929, P = 0.04) was significantly associated with a reduced risk of AKI development.

Conclusions

AKI incidence was increased in patients with decreased liver function and was associated with poor survival. PPI/H2 blocker or kanamycin/rifaximin treatment may reduce the risk of AKI.