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Lum EL, Bunnapradist S, Wiseman AC, Gurakar A, Ferrey A, Reddy U, Al Ammary F. Novel indications for referral and care for simultaneous liver kidney transplant recipients. Curr Opin Nephrol Hypertens 2024; 33:354-360. [PMID: 38345405 PMCID: PMC10990015 DOI: 10.1097/mnh.0000000000000970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
PURPOSE OF REVIEW Kidney dysfunction is challenging in liver transplant candidates to determine whether it is reversible or not. This review focuses on the pertinent data on how to best approach liver transplant candidates with kidney dysfunction in the current era after implementing the simultaneous liver kidney (SLK) allocation policy and safety net. RECENT FINDINGS The implementation of the SLK policy inverted the steady rise in SLK transplants and improved the utilization of high-quality kidneys. Access to kidney transplantation following liver transplant alone (LTA) increased with favorable outcomes. Estimating GFR in liver transplant candidates remains challenging, and innovative methods are needed. SLK provided superior patient and graft survival compared to LTA only for patients with advanced CKD and dialysis at least 3 months. SLK can provide immunological protection against kidney rejection in highly sensitized candidates. Post-SLK transplant care is complex, with an increased risk of complications and hospitalization. SUMMARY The SLK policy improved kidney access and utilization. Transplant centers are encouraged, under the safety net, to reserve SLK for liver transplant candidates with advanced CKD or dialysis at least 3 months while allowing lower thresholds for highly sensitized patients. Herein, we propose a practical approach to liver transplant candidates with kidney dysfunction.
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Affiliation(s)
- Erik L. Lum
- Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - Suphamai Bunnapradist
- Department of Medicine, University of California Los Angeles, Los Angeles, California
| | | | - Ahmet Gurakar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Antoney Ferrey
- Department of Medicine, University of California Irvine, Orange, California, USA
| | - Uttam Reddy
- Department of Medicine, University of California Irvine, Orange, California, USA
| | - Fawaz Al Ammary
- Department of Medicine, University of California Irvine, Orange, California, USA
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2
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Mendez-Guerrero O, Carranza-Carrasco A, Chi-Cervera LA, Torre A, Navarro-Alvarez N. Optimizing nutrition in hepatic cirrhosis: A comprehensive assessment and care approach. World J Gastroenterol 2024; 30:1313-1328. [PMID: 38596498 PMCID: PMC11000076 DOI: 10.3748/wjg.v30.i10.1313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/23/2024] [Accepted: 02/25/2024] [Indexed: 03/14/2024] Open
Abstract
Cirrhosis is considered a growing cause of morbidity and mortality, which represents a significant public health problem. Currently, there is no effective treatment to reverse cirrhosis. Treatment primarily centers on addressing the underlying liver condition, monitoring, and managing portal hypertension-related complications, and evaluating the potential for liver transplantation in cases of decompensated cirrhosis, marked by rapid progression and the emergence of complications like variceal bleeding, hepatic encephalopathy, ascites, malnutrition, and more. Malnutrition, a prevalent complication across all disease stages, is often underdiagnosed in cirrhosis due to the complexities of nutritional assessment in patients with fluid retention and/or obesity, despite its crucial impact on prognosis. Increasing emphasis has been placed on the collaboration of nutritionists within hepatology and Liver transplant teams to deliver comprehensive care, a practice that has shown to improve outcomes. This review covers appropriate screening and assessment methods for evaluating the nutritional status of this population, diagnostic approaches for malnutrition, and context-specific nutrition treatments. It also discusses evidence-based recommendations for supplementation and physical exercise, both essential elements of the standard care provided to cirrhotic patients.
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Affiliation(s)
- Osvely Mendez-Guerrero
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Anaisa Carranza-Carrasco
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Luis Alberto Chi-Cervera
- Clínica de Especialidades Gastrointestinales y Hepáticas, Hospital Star Medica, Merida 97133, Yucatan, Mexico
| | - Aldo Torre
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Nalu Navarro-Alvarez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Molecular Biology, Universidad Panamericana School of Medicine, Campus México, Mexico City 03920, Mexico
- Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO 80045, United States
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3
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Allegretti AS, Patidar KR, Ma AT, Cullaro G. From past to present to future: Terlipressin and hepatorenal syndrome-acute kidney injury. Hepatology 2024:01515467-990000000-00741. [PMID: 38353565 PMCID: PMC11322426 DOI: 10.1097/hep.0000000000000790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/11/2023] [Indexed: 03/01/2024]
Abstract
Hepatorenal syndrome (HRS) is a rare and highly morbid form of kidney injury unique to patients with decompensated cirrhosis. HRS is a physiologic consequence of portal hypertension, leading to a functional kidney injury that can be reversed by restoring effective circulating volume and renal perfusion. While liver transplantation is the only definitive "cure" for HRS, medical management with vasoconstrictors and i.v. albumin is a cornerstone of supportive care. Terlipressin, a V1a receptor agonist that acts on the splanchnic circulation, has been used for many years outside the United States for the treatment of HRS. However, its recent Food and Drug Administration approval has generated new interest in this population, as a new base of prescribers now work to incorporate the drug into clinical practice. In this article, we review HRS pathophysiology and diagnostic criteria, the clinical use of terlipressin and alternative therapies, and identify areas of future research in the space of HRS and kidney injury in cirrhosis.
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Affiliation(s)
- Andrew S. Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kavish R. Patidar
- Section of Gastroenterology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston TX, USA
| | - Ann T. Ma
- Toronto Centre for Liver Disease, University Health Network, Toronto, Canada
| | - Giuseppe Cullaro
- Division of Gastroenterology, Department of Medicine, University of California-San Francisco, San Francisco CA, USA
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4
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Attieh RM, Wadei HM. Acute Kidney Injury in Liver Cirrhosis. Diagnostics (Basel) 2023; 13:2361. [PMID: 37510105 PMCID: PMC10377915 DOI: 10.3390/diagnostics13142361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/01/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
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.
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Affiliation(s)
- Rose Mary Attieh
- Department of Transplant, Division of Kidney and Pancreas Transplant, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Hani M Wadei
- Department of Transplant, Division of Kidney and Pancreas Transplant, Mayo Clinic, Jacksonville, FL 32224, USA
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5
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Griffin C, Asrani SK, Regner KR. Update on Assessment of Estimated Glomerular Filtration Rate in Patients With Cirrhosis. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:307-314. [PMID: 37389536 DOI: 10.1053/j.akdh.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 07/01/2023]
Abstract
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.
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Affiliation(s)
- Connor Griffin
- Division of Hepatology, Baylor University Medical Center, Dallas, TX
| | - Sumeet K Asrani
- Division of Hepatology, Baylor University Medical Center, Dallas, TX
| | - Kevin R Regner
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI.
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6
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Satué K, Fazio E, Medica P, Miguel L, Gardón JC. Biochemical and Hematological Indexes of Liver Dysfunction in Horses. J Equine Vet Sci 2023; 126:104294. [PMID: 36958409 DOI: 10.1016/j.jevs.2023.104294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/17/2023] [Accepted: 03/17/2023] [Indexed: 03/25/2023]
Abstract
In the present review, the authors, based on the multiple functions performed by the liver, analyze the multiple biochemical and hematological changes as an expression of altered liver function in the horse. The liver performs important metabolic functions related to the synthesis, degradation, and excretion of various substances. Modification of these functions can be evaluated and diagnosed by determining serum concentrations of several serum analytes, including enzymes and other endogenous substances. Hepatocellular enzymes, such as sorbitol dehydrogenase-SDH and glutamate dehydrogenase-GLDH, are released following hepatocellular necrosis. Hepatobiliary enzymes, such as γ-glutamyl transferase-GGT, increase in response to necrosis, cholestasis, and other alterations in bile conducts. Serum concentrations of mainly endogenous and exogenous substances that the liver should synthesize or eliminate, such as proteins (albumin and globulins), bile acids, urea, glucose, total and direct bilirubin, and coagulation factors, and fibrinogen should be included in the liver function test profile. The interpretation of laboratory tests of liver function will allow the diagnosis of functional loss of the organ. Some of the analytes considered provide information on the prognosis of liver disease. This review will provide an accurate and objective interpretation of the common biochemical and hematological tests in use in the diagnosis of equine hepatic disease patients, aiding still further the veterinary activity on the applied equine clinical cases.
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Affiliation(s)
- Katiuska Satué
- Department of Animal Medicine and Surgery, Faculty of Veterinary Medicine, CEU-Cardenal Herrera University, Valencia, Spain.
| | - Esterina Fazio
- Department of Veterinary Sciences, Veterinary Physiology Unit, Polo Universitario Annunziata, Messina, Italy
| | - Pietro Medica
- Department of Veterinary Sciences, Veterinary Physiology Unit, Polo Universitario Annunziata, Messina, Italy
| | - Laura Miguel
- Department of Animal Medicine and Surgery, Faculty of Veterinary Medicine, CEU-Cardenal Herrera University, Valencia, Spain
| | - Juan Carlos Gardón
- Department of Animal Medicine and Surgery, Faculty of Veterinary and Experimental Sciences, Catholic University of Valencia-San Vicente Mártir, Valencia, Spain
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Petric M, Jordan T, Karteek P, Licen S, Trotovsek B, Tomazic A. Radiological assessment of skeletal muscle index and myosteatosis and their impact postoperative outcomes after liver transplantation. Radiol Oncol 2023; 57:168-177. [PMID: 37341202 DOI: 10.2478/raon-2023-0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 05/16/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Liver transplantation offers curative treatment to patients with acute and chronic end-stage liver disease. The impact of nutritional status on postoperative outcomes after liver transplantation remains poorly understood. The present study investigated the predictive value of radiologically assessed skeletal muscle index (SMI) and myosteatosis (MI) on postoperative outcomes. PATIENTS AND METHODS Data of 138 adult patients who underwent their first orthotopic liver transplantation were retrospectively analysed. SMI and MI in computer tomography (CT) scan at the third lumbar vertebra level were calculated. Results were analyzed for the length of hospitalisation and postoperative outcomes. RESULTS In 63% of male and 28.9% of female recipients, low SMI was found. High MI was found in 45(32.6%) patients. Male patients with high SMI had longer intensive care unit (ICU) stay (P < 0.025). Low SMI had no influence on ICU stay in female patients (P = 0.544), length of hospitalisation (male, P > 0.05; female, P = 0.843), postoperative complication rates (males, P = 0.883; females, P = 0.113), infection rate (males, P = 0.293, females, P = 0.285) and graft rejection (males, P = 0.875; females, P = 0.135). The presence of MI did not influence ICU stay (P = 0.161), hospitalization (P = 0.771), postoperative complication rates (P = 0.467), infection rate (P = 0.173) or graft rejection rate (P = 0.173). CONCLUSIONS In our study, changes in body composition of liver transplant recipients observed with SMI and MI had no impact on postoperative course after liver transplantation. CT body composition analysis of recipients and uniformly accepted cut-off points are crucial to producing reliable data in the future.
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Affiliation(s)
- Miha Petric
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Taja Jordan
- Institute of Radiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Popuri Karteek
- Department of Computer Science, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Sabina Licen
- Faculty of Health Sciences, University of Primorska, Izola, Slovenia
| | - Blaz Trotovsek
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Ales Tomazic
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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8
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Stämmler F, Derain-Dubourg L, Lemoine S, Meeusen JW, Dasari S, Lieske JC, Robertson A, Schiffer E. Impact of race-independent equations on estimating glomerular filtration rate for the assessment of kidney dysfunction in liver disease. BMC Nephrol 2023; 24:83. [PMID: 37003973 PMCID: PMC10064726 DOI: 10.1186/s12882-023-03136-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 03/23/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Altered hemodynamics in liver disease often results in overestimation of glomerular filtration rate (GFR) by creatinine-based GFR estimating (eGFR) equations. Recently, we have validated a novel eGFR equation based on serum myo-inositol, valine, and creatinine quantified by nuclear magnetic resonance spectroscopy in combination with cystatin C, age and sex (GFRNMR). We hypothesized that GFRNMR could improve chronic kidney disease (CKD) classification in the setting of liver disease. RESULTS We conducted a retrospective multicenter study in 205 patients with chronic liver disease (CLD), comparing the performance of GFRNMR to that of validated CKD-EPI eGFR equations, including eGFRcr (based on creatinine) and eGFRcr-cys (based on both creatinine and cystatin C), using measured GFR as reference standard. GFRNMR outperformed all other equations with a low overall median bias (-1 vs. -6 to 4 ml/min/1.73 m2 for the other equations; p < 0.05) and the lowest difference in bias between reduced and preserved liver function (-3 vs. -16 to -8 ml/min/1.73 m2 for other equations). Concordant classification by CKD stage was highest for GFRNMR (59% vs. 48% to 53%) and less biased in estimating CKD severity compared to the other equations. GFRNMR P30 accuracy (83%) was higher than that of eGFRcr (75%; p = 0.019) and comparable to that of eGFRcr-cys (86%; p = 0.578). CONCLUSIONS Addition of myo-inositol and valine to creatinine and cystatin C in GFRNMR further improved GFR estimation in CLD patients and accurately stratified liver disease patients into CKD stages.
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Affiliation(s)
- Frank Stämmler
- Department of Research and Development, Numares AG,, Am BioPark 9, 93053, Regensburg, Germany
| | - Laurence Derain-Dubourg
- Department Néphrologie, Dialyse, Hypertension Et Exploration Fonctionnelle Rénale, Groupement Hospitalier Edouard Herriot, Hospices Civils de Lyon, Université Claude Bernard, Lyon 1, Lyon, France
| | - Sandrine Lemoine
- Department Néphrologie, Dialyse, Hypertension Et Exploration Fonctionnelle Rénale, Groupement Hospitalier Edouard Herriot, Hospices Civils de Lyon, Université Claude Bernard, Lyon 1, Lyon, France
| | - Jeffrey W Meeusen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Surendra Dasari
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - John C Lieske
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Andrew Robertson
- Department of Research and Development, Numares AG,, Am BioPark 9, 93053, Regensburg, Germany
| | - Eric Schiffer
- Department of Research and Development, Numares AG,, Am BioPark 9, 93053, Regensburg, Germany.
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Wu Y, Xu M, Duan B, Li G, Chen Y. Acute-on-chronic liver failure: clinical course and liver transplantation. Expert Rev Gastroenterol Hepatol 2023; 17:251-262. [PMID: 36779306 DOI: 10.1080/17474124.2023.2180630] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
INTRODUCTION Acute-on-chronic liver failure (ACLF) is a clinical syndrome characterized by intense systemic inflammatory response, multiple-organ failures, and high short-term mortality in patients with chronic liver disease. ACLF is dynamic and heterogeneous, and the prognosis is closely related to the clinical course. Currently, liver transplantation (LT) remains the only potential curative treatment that improves survival of ACLF patients. AREAS COVERED In this review, we summarize the dynamic clinical course of ACLF and the relationship between the clinical course and the post-LT prognosis, especially the factors affecting the mortality after LT in severe ACLF patients and explore the optimal choice of LT therapy for ACLF patients, both to benefit patients the most and to avoid futile therapy. EXPERT OPINION ACLF is a dynamic disease with varying clinical phenotypes, and the global burden is high. Early identification of the clinical course is important to assess the prognosis and guide the treatment. The contradiction between shortage of liver donors and the large number of recipients makes it necessary for us to strictly screen out the recipients and identify patients who really need LT to save liver sources.
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Affiliation(s)
- Yu Wu
- Fourth Department of Liver Disease (Difficult & Complicated Liver Diseases and Artificial Liver Center), Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, China.,Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China
| | - Manman Xu
- Fourth Department of Liver Disease (Difficult & Complicated Liver Diseases and Artificial Liver Center), Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, China.,Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China
| | - Binwei Duan
- Department of General Surgery Center, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, China
| | - Guangming Li
- Department of General Surgery Center, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, China
| | - Yu Chen
- Fourth Department of Liver Disease (Difficult & Complicated Liver Diseases and Artificial Liver Center), Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, China.,Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Beijing, China
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10
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Rodríguez-Perálvarez ML, Gómez-Orellana AM, Majumdar A, Bailey M, McCaughan GW, Gow P, Guerrero M, Taylor R, Guijo-Rubio D, Hervás-Martínez C, Tsochatzis EA. Development and validation of the Gender-Equity Model for Liver Allocation (GEMA) to prioritise candidates for liver transplantation: a cohort study. Lancet Gastroenterol Hepatol 2023; 8:242-252. [PMID: 36528041 DOI: 10.1016/s2468-1253(22)00354-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The Model for End-stage Liver Disease (MELD) and its sodium-corrected variant (MELD-Na) have created gender disparities in accessing liver transplantation. We aimed to derive and validate the Gender-Equity Model for liver Allocation (GEMA) and its sodium-corrected variant (GEMA-Na) to amend such inequities. METHODS In this cohort study, the GEMA models were derived by replacing creatinine with the Royal Free Hospital glomerular filtration rate (RFH-GFR) within the MELD and MELD-Na formulas, with re-fitting and re-weighting of each component. The new models were trained and internally validated in adults listed for liver transplantation in the UK (2010-20; UK Transplant Registry) using generalised additive multivariable Cox regression, and externally validated in an Australian cohort (1998-2020; Royal Prince Alfred Hospital [Australian National Liver Transplant Unit] and Austin Hospital [Victorian Liver Transplant Unit]). The study comprised 9320 patients: 5762 patients for model training, 1920 patients for internal validation, and 1638 patients for external validation. The primary outcome was mortality or delisting due to clinical deterioration within the first 90 days from listing. Discrimination was assessed by Harrell's concordance statistic. FINDINGS 449 (5·8%) of 7682 patients in the UK cohort and 87 (5·3%) of 1638 patients in the Australian cohort died or were delisted because of clinical deterioration within 90 days. GEMA showed improved discrimination in predicting mortality or delisting due to clinical deterioration within the first 90 days after waiting list inclusion compared with MELD (Harrell's concordance statistic 0·752 [95% CI 0·700-0·804] vs 0·712 [0·656-0·769]; p=0·001 in the internal validation group and 0·761 [0·703-0·819] vs 0·739 [0·682-0·796]; p=0·036 in the external validation group), and GEMA-Na showed improved discrimination compared with MELD-Na (0·766 [0·715-0·818] vs 0·742 [0·686-0·797]; p=0·0058 in the internal validation group and 0·774 [0·720-0·827] vs 0·745 [0·690-0·800]; p=0·014 in the external validation group). The discrimination capacity of GEMA-Na was higher in women than in the overall population, both in the internal (0·802 [0·716-0·888]) and external validation cohorts (0·796 [0·698-0·895]). In the pooled validation cohorts, GEMA resulted in a score change of at least 2 points compared with MELD in 1878 (52·8%) of 3558 patients (25·0% upgraded and 27·8% downgraded). GEMA-Na resulted in a score change of at least 2 points compared with MELD-Na in 1836 (51·6%) of 3558 patients (32·3% upgraded and 19·3% downgraded). In the whole cohort, 3725 patients received a transplant within 90 days of being listed. Of these patients, 586 (15·7%) would have been differently prioritised by GEMA compared with MELD; 468 (12·6%) patients would have been differently prioritised by GEMA-Na compared with MELD-Na. One in 15 deaths could potentially be avoided by using GEMA instead of MELD and one in 21 deaths could potentially be avoided by using GEMA-Na instead of MELD-Na. INTERPRETATION GEMA and GEMA-Na showed improved discrimination and a significant re-classification benefit compared with existing scores, with consistent results in an external validation cohort. Their implementation could save a clinically meaningful number of lives, particularly among women, and could amend current gender inequities in accessing liver transplantation. FUNDING Junta de Andalucía and EDRF.
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Affiliation(s)
- Manuel Luis Rodríguez-Perálvarez
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, IMIBIC, Córdoba, Spain; Department of Medicine, University of Córdoba, Córdoba, Spain; Centro de investigación biomédica en red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | | | - Avik Majumdar
- AW Morrow Gastroenterology and Liver Centre and Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Central Clinical School, The University of Sydney, Sydney, NSW, Australia; Victorian Liver Transplant Unit, Austin Health, Melbourne, VIC, Australia; The University of Melbourne, Melbourne, VIC, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; ANZICS Centre for Outcome and Resource Evaluation (CORE), Melbourne, VIC, Australia
| | - Geoffrey W McCaughan
- AW Morrow Gastroenterology and Liver Centre and Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Central Clinical School, The University of Sydney, Sydney, NSW, Australia; Liver Injury and Cancer Program, Centenary Institute, Sydney, NSW, Australia
| | - Paul Gow
- Victorian Liver Transplant Unit, Austin Health, Melbourne, VIC, Australia; The University of Melbourne, Melbourne, VIC, Australia
| | - Marta Guerrero
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, IMIBIC, Córdoba, Spain; Centro de investigación biomédica en red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - Rhiannon Taylor
- Department of Statistics and Clinical Studies, NHS Blood and Transplant, Stoke Gifford, Bristol, UK
| | - David Guijo-Rubio
- Department of Computer Science and Numerical Analysis, University of Córdoba, Córdoba, Spain; School of Computing Sciences, University of East Anglia, Norwich, UK
| | - César Hervás-Martínez
- Department of Computer Science and Numerical Analysis, University of Córdoba, Córdoba, Spain
| | - Emmanuel A Tsochatzis
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK.
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11
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Predictive value of lipocalin 2 and cystatin C for acute kidney injury in patients with cirrhosis. Hepatobiliary Pancreat Dis Int 2023; 22:99-103. [PMID: 36402665 DOI: 10.1016/j.hbpd.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 11/07/2022] [Indexed: 11/13/2022]
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12
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Yewale RV, Ramakrishna BS. Novel biomarkers of acute kidney injury in chronic liver disease: Where do we stand after a decade of research? Hepatol Res 2023; 53:3-17. [PMID: 36262036 DOI: 10.1111/hepr.13847] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/06/2022] [Accepted: 10/14/2022] [Indexed: 01/03/2023]
Abstract
Acute kidney injury (AKI) is a frequently encountered complication in decompensated chronic liver disease (CLD) with an estimated prevalence of 20%-50% among hospitalized patients. AKI often heralds the onset of a downhill course in the natural history of CLD. Serum creatinine has several limitations as a stand-alone marker of AKI in patients with decompensated CLD. The concept of hepatorenal syndrome, the prototype of AKI in decompensated CLD, has evolved tremendously over recent years. There is emerging evidence of an additional "structural" component in the pathophysiology of hepatorenal syndrome-AKI, which was previously identified as a purely "functional" form of renal impairment. Lacunae in the existent biochemical arsenal for diagnosis and prognosis of AKI have fueled enthusiastic research in the field of novel biomarkers of kidney injury in patients with cirrhosis. The advent of these biomarkers provides a crucial window of opportunity to improve the diagnosis and clinical outcomes of this vulnerable cohort of patients. This review summarizes the dynamic concept of renal dysfunction in CLD and the available literature on the role of novel biomarkers of AKI in assessing renal function, identifying AKI subtypes, and predicting prognosis. There is special emphasis on the renal tubular injury marker, neutrophil gelatinase-associated lipocalin, the most exhaustively studied biomarker of AKI in the CLD population.
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Affiliation(s)
- Rohan Vijay Yewale
- Institute of Gastroenterology, Hepatobiliary Sciences and Transplantation, SRM Institutes for Medical Science, Chennai, India
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Campion D, Rizzi F, Bonetto S, Giovo I, Roma M, Saracco GM, Alessandria C. Assessment of glomerular filtration rate in patients with cirrhosis: Available tools and perspectives. Liver Int 2022; 42:2360-2376. [PMID: 35182100 DOI: 10.1111/liv.15198] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 11/08/2021] [Accepted: 12/09/2021] [Indexed: 12/07/2022]
Abstract
Renal dysfunction often complicates the course of liver disease, resulting in higher morbidity and mortality. The accurate assessment of kidney function in these patients is essential to early identify, stage and treat renal impairment as well as to better predict the prognosis, prioritize the patients for liver transplantation and decide whether to opt for simultaneous liver-kidney transplants. This review analyses the available tools for direct or indirect assessment of glomerular filtration rate, focusing on the flaws and strengths of each method in the specific setting of cirrhosis. The aim is to deliver a clear-cut view on this complex issue, trying to point out which strategies to prefer in this context, especially in the peculiar setting of liver transplantation. Moreover, a glance is given at future promising tools for glomerular filtration rate assessment, including new biomarkers and new equations specifically modelled for the cirrhotic population.
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Affiliation(s)
- Daniela Campion
- Department of Gastroenterology and Hepatology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Felice Rizzi
- Department of Gastroenterology and Hepatology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Silvia Bonetto
- Department of Gastroenterology and Hepatology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Ilaria Giovo
- Department of Gastroenterology and Hepatology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Michele Roma
- Department of Gastroenterology and Hepatology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Giorgio M Saracco
- Department of Gastroenterology and Hepatology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Carlo Alessandria
- Department of Gastroenterology and Hepatology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
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14
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Cai X, Thorand B, Hohenester S, Koenig W, Rathmann W, Peters A, Nano J. Association between the fatty liver index and chronic kidney disease: the population-based KORA study. Nephrol Dial Transplant 2022; 38:1240-1248. [PMID: 36150717 DOI: 10.1093/ndt/gfac266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We aimed to evaluate the relationship of fatty liver, estimated by fatty liver index (FLI), with kidney function and chronic kidney disease (CKD) in a German cohort study, given the lack of prospective evidence in Europeans. METHODS We included 2920 participants (51.6% women, mean age 56.1 years) from the KORA study, of which 1991 were followed up for an average of 6.4 (± 0.3) years. Kidney function was assessed using the glomerular filtration rate estimated by creatinine (eGFR-cr) or cystatin C (eGFR-cc). We used multiple logistic or linear regressions to evaluate the associations between FLI, kidney function and CKD (eGFR < 60 ml/min per 1.73 m2), and mediation analysis to explore the mediation effects of metabolic factors. RESULTS The prevalence of FLI ≥ 60 and CKD were 40.4% and 5.6% at baseline, and 182 participants developed CKD during the follow-up. Cross-sectionally, FLI was significantly inversely associated with eGFR-cc [β, 95%CI: -1.14 (-1.81, -0.47)] and prevalent CKD based on eGFR-cc [OR, 95%CI: 1.28 (1.01, 1.61)], but not with other markers. After adjusting for lifestyle factors, we found a positive association between FLI and incident CKD defined by eGFR-cc or/eGFR-cr, which was attenuated after controlling for metabolic risk factors. Mediation analysis showed that the association was completely mediated by inflammation, diabetes and hypertension jointly. CONCLUSIONS The positive association between FLI and CKD incidence was fully mediated by the joint effect of metabolic risk factors. Future longitudinal studies need to explore the chronological interplay between fatty liver, cardiometabolic risk factors and kidney function with repeated measurements.
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Affiliation(s)
- Xinting Cai
- Institute of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany.,Institute for Medical Information Processing, Biometry, and Epidemiology - IBE, Ludwig-Maximilians University of Munich, Munich, Germany.,Pettenkofer School of Public Health, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Barbara Thorand
- Institute of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany.,German Center for Diabetes Research (DZD), partner site Munich-Neuherberg, Neuherberg, Germany
| | - Simon Hohenester
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Disease Research (DZHK), partner site Munich Heart Alliance, Munich, Germany.,Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center at Heinrich-Heine University, Düsseldorf, Germany.,German Center for Diabetes Research (DZD), partner site Düsseldorf, Neuherberg, Germany
| | - Annette Peters
- Institute of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany.,Institute for Medical Information Processing, Biometry, and Epidemiology - IBE, Ludwig-Maximilians University of Munich, Munich, Germany.,German Center for Diabetes Research (DZD), partner site Munich-Neuherberg, Neuherberg, Germany.,German Center for Cardiovascular Disease Research (DZHK), partner site Munich Heart Alliance, Munich, Germany
| | - Jana Nano
- Institute of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany.,Department of Epidemiology, Institute for Medical Information Processing, Biometry and Epidemiology-IBE, Ludwig-Maximilians-University Munich, Munich, Germany
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15
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Carrier P, Destere A, Giguet B, Debette-Gratien M, Essig M, Monchaud C, Woillard JB, Loustaud-Ratti V. Iohexol plasma and urinary concentrations in cirrhotic patients: A pilot study. World J Hepatol 2022; 14:1621-1632. [PMID: 36157874 PMCID: PMC9453460 DOI: 10.4254/wjh.v14.i8.1621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/11/2022] [Accepted: 06/24/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Renal failure is an independent prognostic factor for survival in patients with cirrhosis. Equations to calculate serum creatinine significantly overestimate the glomerular filtration rate (GFR). Plasma clearance of direct biomarkers has been used to improve the accuracy of evaluations of GFR in this population, but no study has simultaneously measured plasma and urinary clearance, which is the gold standard.
AIM To study calculated plasma and urinary concentrations of iohexol, based on the kinetics of samples collected over 24 h from cirrhotic patients with three different grades of ascites.
METHODS One dose of iohexol (5 mL) was injected intravenously and plasma concentrations were measured 11 times over 24 h in nine cirrhotic patients. The urinary concentration of iohexol was also measured, in urine collected at 4, 8, 12 and 24 h.
RESULTS The plasma and urinary curves of iohexol were similar; however, incomplete urinary excretion was detected at 24 h. Within the estimated GFR limits of our population (> 30 and < 120 mL/min/1.73 m²), the median measured GFR (mGFR) was 63.7 mL/min/1.73 m² (range: 41.3–111.3 mL/min/1.73 m²), which was an accurate reflection of the actual GFR. Creatinine-based formulas for estimating GFR showed significant bias and imprecision, while the Brochner–Mortensen (BM) equation accurately estimated the mGFR (r = 0.93).
CONCLUSION Plasma clearance of iohexol seems useful for determining GFR regardless of the ascites grade. We will secondly devise a pharmacokinetics model requiring fewer samples andvalidate the BM equation.
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Affiliation(s)
- Paul Carrier
- Department of Liver Disease, Limoges University Hospital Center, U1248, INSERM, F-87000, Limoges, France
| | - Alexandre Destere
- Department of Pharmacology, Toxicology and Centre of Pharmacovigilance, Limoges University Hospital Center, U1248, INSERM, F-87000, Limoges, France
| | - Baptiste Giguet
- Department of Liver Disease, Limoges University Hospital Center, U1248, INSERM, F-87000, Limoges, France
| | - Marilyne Debette-Gratien
- Department of Liver Disease, Limoges University Hospital Center, U1248, INSERM, F-87000, Limoges, France
| | - Marie Essig
- Department of Pharmacology, Toxicology and Centre of Pharmacovigilance, Limoges University Hospital Center, U1248, INSERM, F-87000, Limoges, France
| | - Caroline Monchaud
- Department of Pharmacology, Toxicology and Centre of Pharmacovigilance, Limoges University Hospital Center, U1248, INSERM, F-87000, Limoges, France
| | - Jean-Baptiste Woillard
- Department of Pharmacology, Toxicology and Centre of Pharmacovigilance, Limoges University Hospital Center, U1248, INSERM, F-87000, Limoges, France
| | - Véronique Loustaud-Ratti
- Department of Liver Disease, Limoges University Hospital Center, U1248, INSERM, F-87000, Limoges, France
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Fürschuß L, Rainer F, Effenberger M, Niederreiter M, Portugaller RH, Horvath A, Fickert P, Stadlbauer V. A novel score predicts mortality after transjugular intrahepatic portosystemic shunt: MOTS - Modified TIPS Score. Liver Int 2022; 42:1849-1860. [PMID: 35261130 PMCID: PMC9539997 DOI: 10.1111/liv.15236] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 02/04/2022] [Accepted: 03/02/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS The high risk for severe shunting-related post-interventional complications demands a stringent selection of candidates for transjugular intrahepatic portosystemic shunt (TIPS). We aimed to develop a simple and reliable tool to accurately predict early post-TIPS mortality. METHODS 144 cases of TIPS implantation were retrospectively analysed. Using univariate and multivariate Cox regression analysis of factors predicting mortality within 90 days after TIPS, a score integrating urea, international normalized ratio (INR) and bilirubin was developed. The Modified TIPS-Score (MOTS) ranges from 0 to 3 points: INR >1.6, urea >71 mg/dl and bilirubin >2.2 mg/dl account for one point each. Additionally, MOTS was tested in an external validation cohort (n = 187) and its performance was compared to existing models. RESULTS Modified TIPS-Score achieved a significant prognostic discrimination reflected by 90-day mortality of 8% in patients with MOTS 0-1 and 60% in patients with MOTS 2-3 (p < .001). Predictive performance (area under the curve) of MOTS was accurate (c = 0.845 [0.73-0.96], p < .001), also in patients with renal insufficiency (c = 0.830 [0.64-1.00], p = .02) and in patients with refractory ascites (c = 0.949 [0.88-1.00], p < .001), which are subgroups with particular room for improvement of post-TIPS mortality prediction. The results were reproducible in the validation cohort. CONCLUSIONS Modified TIPS-Score is a novel, practicable tool to predict post-TIPS mortality, that can significantly simplify clinical decision making. Its practical applicability should be further investigated.
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Affiliation(s)
- Luisa Fürschuß
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria
| | - Florian Rainer
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria
| | - Maria Effenberger
- Department of Internal Medicine I, Gastroenterology, Hepatology and Endocrinology & Metabolism, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Niederreiter
- Department of Internal Medicine I, Gastroenterology, Hepatology and Endocrinology & Metabolism, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert H Portugaller
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Angela Horvath
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria
- Centre for Biomarker Research in Medicine (CBmed), Graz, Austria
| | - Peter Fickert
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria
| | - Vanessa Stadlbauer
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria
- Centre for Biomarker Research in Medicine (CBmed), Graz, Austria
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Ponzo P, Campion D, Rizzo M, Roma M, Caviglia GP, Giovo I, Rizzi F, Bonetto S, Saracco GM, Alessandria C. Transjugular intrahepatic porto-systemic shunt in cirrhotic patients with hepatorenal syndrome - chronic kidney disease: Impact on renal function. Dig Liver Dis 2022; 54:1101-1108. [PMID: 34625366 DOI: 10.1016/j.dld.2021.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Transjugular intrahepatic porto-systemic shunt (TIPS) ameliorates renal function in type-2 hepatorenal syndrome (HRS). Available evidence is based on 'old' HRS diagnostic criteria, and not on the current definition of HRS - chronic kidney disease (HRS-CKD). Among patients who underwent TIPS for refractory ascites over the last 12 years, we investigated clinical and renal function evolution of those with HRS-CKD. METHODS among 212 patients, 41 with HRS-CKD were included. Renal function was evaluated for 12 months after TIPS, along with management of ascites and transplant-free survival (TFS). RESULTS renal function significantly improved already one week after TIPS [serum creatinine (sCr): 1.37 ± 0.23 vs 1.94 ± 0.54 mg/dl, p< 0.001]; the amelioration was maintained during the whole follow-up and was observed in every CKD stage, defined according to baseline estimated Glomerular Filtration Rate (eGFR). sCr and eGFR became comparable between different CKD stages after only one week, whilst significantly different at baseline. TIPS led to a remarkable improvement in the control of ascites in all CKD stages and no significant differences in TFS were recorded. CONCLUSIONS TIPS led to an early, substantial and persistent improvement in renal function in patients with HRS-CKD, irrespective of their baseline CKD stage.
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Affiliation(s)
- Paola Ponzo
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Daniela Campion
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Martina Rizzo
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Michele Roma
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Gian Paolo Caviglia
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Ilaria Giovo
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Felice Rizzi
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Silvia Bonetto
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Giorgio Maria Saracco
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy.
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MELD-GRAIL and MELD-GRAIL-Na Are Not Superior to MELD or MELD-Na in Predicting Liver Transplant Waiting List Mortality at a Single-center Level. Transplant Direct 2022; 8:e1346. [PMID: 35706607 PMCID: PMC9191558 DOI: 10.1097/txd.0000000000001346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/10/2022] [Indexed: 11/27/2022] Open
Abstract
Controversy exists regarding the best predictive model of liver transplant waiting list (WL) mortality. Models for end-stage liver disease–glomerular filtration rate assessment in liver disease (MELD-GRAIL) and MELD-GRAIL-Na were recently described to provide better prognostication, particularly in females. We evaluated the performance of these scores compared to MELD and MELD-Na.
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Petrič M, Jordan T, Popuri K, Ličen S, Trotovšek B, Tomažič A. WITHDRAWN: Do skeletal muscle index and myosteatosis impact postoperative outcomes after liver transplantation? JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2022.100106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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20
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Panchal S, Serper M, Bittermann T, Asrani SK, Goldberg DS, Mahmud N. Impact of Race-Adjusted Glomerular Filtration Rate Estimation on Eligibility for Simultaneous Liver-Kidney Transplantation. Liver Transpl 2022; 28:959-968. [PMID: 34558791 PMCID: PMC8943444 DOI: 10.1002/lt.26310] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/31/2021] [Accepted: 09/01/2021] [Indexed: 12/31/2022]
Abstract
Estimated glomerular filtration rate (eGFR) is adjusted for Black race in commonly used formulas. This has potential implications for access to simultaneous liver-kidney transplantation (SLKT) as qualifying criteria rely on eGFR. We performed a retrospective study of United Network for Organ Sharing national transplant registry data between February 28, 2002, and March 31, 2019, to evaluate the proportion of Black patients who would be reclassified as meeting SLKT criteria (as defined per current policies) if race adjustment were removed from 2 prominent eGFR equations (Modification of Diet in Renal Disease-4 [MDRD-4] and Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI]). Of the 7937 Black patients listed for transplant during the study period, we found that 3.6% would have been reclassified as qualifying for chronic kidney disease (CKD)-related SLKT with removal of race adjustment for MDRD-4, and 3.0% would have been reclassified with CKD-EPI; this represented 23.7% and 18.7% increases in SLKT candidacy, respectively. Reclassification impacted women more than men (eg, 4.5% versus 3.0% by MDRD-4; P < 0.05). In an exploratory analysis, patients meeting SLKT criteria by race-unadjusted eGFR equations were significantly more likely to receive liver transplantation alone (LTA) compared with SLKT. Approximately 2.0% of reclassified patients required kidney transplantation within 1 year of LTA versus 0.3% of nonreclassified patients. In conclusion, race adjustment in eGFR equations may impact SLKT candidacy for 3.0% to 4.0% of Black patients listed for LTA overall. Approximately 2.0% of patients reclassified as meeting SLKT criteria require short-term post-LTA kidney transplantation. These data argue for developing novel algorithms for glomerular filtration rate estimation free of race to promote equity.
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Affiliation(s)
- Sarjukumar Panchal
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sumeet K. Asrani
- Baylor University Medical Center, Baylor Scott and White, Dallas, Texas
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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21
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Are MELD and MELDNa Still Reliable Tools to Predict Mortality on the Liver Transplant Waiting List? Transplantation 2022; 106:2122-2136. [PMID: 35594480 DOI: 10.1097/tp.0000000000004163] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Liver transplantation is the only curative treatment for end-stage liver disease. Unfortunately, the scarcity of donor organs and the increasing pool of potential recipients limit access to this life-saving procedure. Allocation should account for medical and ethical factors, ensuring equal access to transplantation regardless of recipient's gender, race, religion, or income. Based on their short-term prognosis prediction, model for end-stage liver disease (MELD) and MELD sodium (MELDNa) have been widely used to prioritize patients on the waiting list for liver transplantation resulting in a significant decrease in waiting list mortality/removal. Recent concern has been raised regarding the prognostic accuracy of MELD and MELDNa due, in part, to changes in recipients' profile such as body mass index, comorbidities, and general condition, including nutritional status and cause of liver disease, among others. This review aims to provide a comprehensive view of the current state of MELD and MELDNa advantages and limitations and promising alternatives. Finally, it will explore future options to increase the donor pool and improve donor-recipient matching.
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22
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The Evolution of the MELD Score and Its Implications in Liver Transplant Allocation: A Beginner's Guide for Trainees. ACG Case Rep J 2022; 9:e00763. [PMID: 35919673 PMCID: PMC9287268 DOI: 10.14309/crj.0000000000000763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Buccheri S, Da BL. Hepatorenal Syndrome: Definitions, Diagnosis, and Management. Clin Liver Dis 2022; 26:181-201. [PMID: 35487604 DOI: 10.1016/j.cld.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hepatorenal syndrome (HRS) is a hemodynamically driven process mediated by renal dysregulation and inflammatory response. Albumin, antibiotics, and β-blockers are among therapies that have been studied in HRS prevention. There are no Food and Drug Administration-approved treatments for HRS although multiple liver societies have recommended terlipressin as first-line pharmacotherapy. Renal replacement therapy is the primary modality used to bridge to definitive therapy with orthotopic liver transplant or simultaneous liver-kidney transplant. Advances in our understanding of HRS pathophysiology and emerging therapeutic modalities are needed to change outcomes for this vulnerable population.
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Affiliation(s)
- Sebastiano Buccheri
- Department of Internal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, 400 Community Drive, Manhasset, NY 11030, USA
| | - Ben L Da
- Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases & Transplantation, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, 400 Community Drive, Manhasset, NY 11030, USA.
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Kidney injury after lung transplantation: Long-term mortality predicted by post-operative day-7 serum creatinine and few clinical factors. PLoS One 2022; 17:e0265002. [PMID: 35245339 PMCID: PMC8896732 DOI: 10.1371/journal.pone.0265002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/20/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) after lung transplantation (LuTx) is associated with increased long-term mortality. In this prospective observational study, commonly used AKI-definitions were examined regarding prediction of long-term mortality and compared to simple use of the serum creatinine value at day 7 for patients who did not receive hemodialysis, and serum creatinine value immediately before initiation of hemodialysis (d7/preHD-sCr). METHODS 185 patients with LuTx were prospectively enrolled from 2013-2014 at our center. Kidney injury was assessed within 7 days by: (1) the Kidney Disease Improving Global Outcomes criteria (KDIGO-AKI), (2) the Acute Disease Quality Initiative 16 Workgroup classification (ADQI-AKI) and (3) d7/preHD-sCr. Prediction of all-cause mortality was examined by Cox regression analysis, and clinical as well as laboratory factors for impaired kidney function post-LuTx were analyzed. RESULTS AKI according to KDIGO and ADQI-AKI occurred in 115 patients (62.2%) within 7 days after LuTx. Persistent ADQI-AKI, KDIGO-AKI stage 3 and higher d7/preHD-sCr were associated with higher mortality in the univariable analysis. In the multivariable analysis, d7/preHD-sCr in combination with body weight and intra- and postoperative platelet transfusions predicted mortality after LuTx with similar performance as models using KDIGO-AKI and ADQI-AKI (concordance index of 0.75 for d7/preHD-sCr vs., 0.74 and 0.73, respectively). Pre-transplant reduced renal function, diabetes, higher BMI, and intraoperative ECMO predicted higher d7/preHD-sCr (r2 = 0.354, p < 0.001). CONCLUSION Our results confirm the importance of AKI in lung transplant patients; however, a simple and pragmatic indicator of renal function, d7/preHD-sCr, predicts long-term mortality equally reliable as more complex AKI-definitions like KDIGO and ADQI.
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Mahmud N, Asrani SK, Reese PP, Kaplan DE, Taddei TH, Nadim MK, Serper M. Race Adjustment in eGFR Equations Does Not Improve Estimation of Acute Kidney Injury Events in Patients with Cirrhosis. Dig Dis Sci 2022; 67:1399-1408. [PMID: 33761091 PMCID: PMC8460692 DOI: 10.1007/s10620-021-06943-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/06/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Accuracy of glomerular filtration rate estimating (eGFR) equations has significant implications in cirrhosis, potentially guiding simultaneous liver kidney allocation and drug dosing. Most equations adjust for Black race, partially accounted for by reported differences in muscle mass by race. Patients with cirrhosis, however, are prone to sarcopenia which may mitigate such differences. We evaluated the association between baseline eGFR and incident acute kidney injury (AKI) in patients with cirrhosis with and without race adjustment. METHODS We conducted a retrospective national cohort study of veterans with cirrhosis. Baseline eGFR was calculated using multiple eGFR equations including Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), both with and without race adjustment. Poisson regression was used to investigate the association between baseline eGFR and incident AKI events per International Club of Ascites criteria. RESULTS We identified 72,267 patients with cirrhosis, who were 97.3% male, 57.8% white, and 19.7% Black. Over median follow-up 2.78 years (interquartile range 1.22-5.16), lower baseline eGFR by CKD-EPI was significantly associated with higher rates of AKI in adjusted models. For all equations this association was minimally impacted when race adjustment was removed. For example, removal of race adjustment from CKD-EPI resulted in a 0.1% increase in the association between lower eGFR and higher rate of AKI events per 15 mL/min/1.73 m2 change (p < 0.001). CONCLUSIONS Race adjustment in eGFR equations did not enhance AKI risk estimation in patients with cirrhosis. Further study is warranted to assess the impacts of removing race from eGFR equations on clinical outcomes and policy.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA.
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Sumeet K Asrani
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX, USA
| | - Peter P Reese
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Tamar H Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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González-Alayón C, Porrini E, Luis-Lima S, Negrín-Mena N, Moreno M, Morales-Arráez D, González-Rinne F, Díaz-Martín L, Gaspari F, González-Delgado A, Ferrer-Moure C, Ortiz-Arduán A, Hernandez-Guerra M. Estimated glomerular filtration rate by formulas in patients with cirrhosis: An unreliable procedure. Liver Int 2022; 42:884-895. [PMID: 34951102 DOI: 10.1111/liv.15134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 11/22/2021] [Accepted: 12/09/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS In cirrhosis, the reliability of formulas that estimate renal function, either those specifically developed in this population or the classic equations, has not been properly quantified. We studied the agreement between estimated (eGFR) and measured glomerular filtration rate (mGFR) in cirrhosis. METHODS Renal function was estimated with 56 formulas including specific equations: Glomerular Filtration Rate Assessment in Liver Disease (GRAIL), Royal Free Hospital Cirrhosis (RFHC) and Mindikoglu-eGFR, and measured with a gold standard procedure; plasma clearance of iohexol using dried blood spots sampling in a group of cirrhotics. The agreement eGFR-mGFR was evaluated with specific tests: total deviation index (TDI), concordance correlation coefficient (CCC) and coverage probability (CP). We defined acceptable agreement as values: TDI < 10%, CCC ≥ 0.9 and CP > 90%. RESULTS A total of 146 patients (age 65 ± 9 years, 81% male) were evaluated; 61 (42%) Child A, 67 (46%) Child B and 18 (12%) Child C. Median MELD-Na was 14 (9-15). The agreement between eGFR and mGFR was poor: TDI averaged was of 73% (90% of the estimations ranged from ±73% of mGFR); CCC averaged was 0.7 indicating low concordance and CP averaged 22% indicating that 78% of the estimations have an error > 10%. Specific formulas showed also poor agreement: TDI was 82%, 70% and 37% for the GRAIL, RFHC and Mindikoglu equations, respectively. CONCLUSIONS Overall, formulas poorly estimated renal function in cirrhotic patients. Specific formulas designed for cirrhosis did not outperform classic equations. eGFR must be considered with caution in cirrhotic patients.
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Affiliation(s)
| | - Esteban Porrini
- Laboratory of Renal Function (LFR), Faculty of Medicine, University of La Laguna, La Laguna, Spain.,Faculty of Medicine, Instituto de Tecnologías Biomédicas (ITB), University of La Laguna, La Laguna, Spain
| | - Sergio Luis-Lima
- Laboratory of Renal Function (LFR), Faculty of Medicine, University of La Laguna, La Laguna, Spain.,IIS-Fundación Jiménez Diaz, Department of Medicine, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Natalia Negrín-Mena
- Research Unit Department, Hospital Universitario de Canarias (HUC), La Laguna, Spain
| | - Miguel Moreno
- Liver Unit, Hospital Universitario de Canarias (HUC), La Laguna, Spain
| | | | - Federico González-Rinne
- Laboratory of Renal Function (LFR), Faculty of Medicine, University of La Laguna, La Laguna, Spain
| | - Laura Díaz-Martín
- Laboratory of Renal Function (LFR), Faculty of Medicine, University of La Laguna, La Laguna, Spain
| | - Flavio Gaspari
- Laboratory of Renal Function (LFR), Faculty of Medicine, University of La Laguna, La Laguna, Spain
| | | | - Carmen Ferrer-Moure
- Clinical Laboratory, Hospital Universitario de Canarias (HUC), La Laguna, Spain
| | - Alberto Ortiz-Arduán
- Laboratory of Renal Function (LFR), Faculty of Medicine, University of La Laguna, La Laguna, Spain.,Red de Investigación Renal (REDinREN), Instituto Salud Carlos III-FEDER, Madrid, Spain
| | - Manuel Hernandez-Guerra
- Liver Unit, Hospital Universitario de Canarias (HUC), La Laguna, Spain.,Faculty of Medicine, Instituto de Tecnologías Biomédicas (ITB), University of La Laguna, La Laguna, Spain
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Brodosi L, Petta S, Petroni ML, Marchesini G, Morelli MC. Management of Diabetes in Candidates for Liver Transplantation and in Transplant Recipients. Transplantation 2022; 106:462-478. [PMID: 34172646 PMCID: PMC9904447 DOI: 10.1097/tp.0000000000003867] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 11/25/2022]
Abstract
Diabetes is common in patients waitlisted for liver transplantation because of end-stage liver disease or hepatocellular cancer as well as in posttransplant phase (posttransplantation diabetes mellitus). In both conditions, the presence of diabetes severely affects disease burden and long-term clinical outcomes; careful monitoring and appropriate treatment are pivotal to reduce cardiovascular events and graft and recipients' death. We thoroughly reviewed the epidemiology of diabetes in the transplant setting and the different therapeutic options, from lifestyle intervention to antidiabetic drug use-including the most recent drug classes available-and to the inclusion of bariatric surgery in the treatment cascade. In waitlisted patients, the old paradigm that insulin should be the treatment of choice in the presence of severe liver dysfunction is no longer valid; novel antidiabetic agents may provide adequate glucose control without the risk of hypoglycemia, also offering cardiovascular protection. The same evidence applies to the posttransplant phase, where oral or injectable noninsulin agents should be considered to treat patients to target, limiting the impact of disease on daily living, without interaction with immunosuppressive regimens. The increasing prevalence of liver disease of metabolic origin (nonalcoholic fatty liver) among liver transplant candidates, also having a higher risk of noncirrhotic hepatocellular cancer, is likely to accelerate the acceptance of new drugs and invasive procedures, as suggested by international guidelines. Intensive lifestyle intervention programs remain however mandatory, both before and after transplantation. Achievement of adequate control is mandatory to increase candidacy, to prevent delisting, and to improve long-term outcomes.
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Affiliation(s)
- Lucia Brodosi
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, PROMISE, University of Palermo, Palermo, Italy
| | - Maria L. Petroni
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
| | - Giulio Marchesini
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
| | - Maria C. Morelli
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Bittermann T, Abt PL, Olthoff KM, Kaur N, Heimbach JK, Emamaullee J. Impact of Advanced Renal Dysfunction on Posttransplant Outcomes After Living Donor Liver Transplantation in the United States. Transplantation 2021; 105:2564-2570. [PMID: 33660658 PMCID: PMC8410875 DOI: 10.1097/tp.0000000000003728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Survival after living donor liver transplantation (LDLT) in the United States is excellent. However, the significance of pretransplant kidney disease on outcomes in this population is poorly understood. METHODS This was a retrospective cohort study of 2806 LDLT recipients nationally between January 2010 and June 2020. Recipients with estimated glomerular filtration rate <40 mL/min/1.73 m2 (eGFR-low) or requiring dialysis were compared. Multivariable survival analyses evaluated (1) eGFR-low as a predictor of post-LDLT survival and (2) the survival of LDLT versus deceased donor liver transplant (DDLT) alone with eGFR-low. RESULTS From 2010 to 2020, 140 (5.0%) patients had eGFR-low and 18 (0.6%) required dialysis pre-LDLT. The number of LDLTs requiring dialysis between 2017 and 2020 outnumbered the prior 7 y. Overall LDLT experience was greater at centers performing LDLT in recipients with renal dysfunction (P < 0.001). LDLT recipients with eGFR-low had longstanding renal dysfunction: mean eGFR 3-6 mo before LDLT 42.7 (±15.1) mL/min/1.73 m2. Nearly half (5/12) of eGFR-low recipients with active kidney transplant (KT) listing at LDLT experienced renal recovery. Five patients underwent early KT after LDLT via the new "safety net" policy. Unadjusted survival after LDLT was worse with eGFR-low (hazard ratio 2.12 versus eGFR ≥40 mL/min/1.73 m2; 95% confidence interval, 1.47-3.05; P < 0.001), but no longer so when accounting for mean eGFR 3-6 mo pre-LDLT (hazard ratio, 1.27; 95% confidence interval, 0.82-1.95; P = 0.3). The adjusted survival of patients with eGFR-low receiving LDLT versus deceased donor liver transplant alone was not different (P = 0.08). CONCLUSIONS Overall, outcomes after LDLT with advanced renal dysfunction are acceptable. These findings are relevant given the recent "safety net" KT policy.
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Affiliation(s)
- Therese Bittermann
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
- Division of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Peter L. Abt
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA
| | - Kim M. Olthoff
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA
| | - Navpreet Kaur
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Julie K. Heimbach
- Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN
| | - Juliet Emamaullee
- Department of Surgery, University of Southern California, Los Angeles, CA
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29
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Singapura P, Ma TW, Sarmast N, Gonzalez SA, Durand F, Maiwall R, Nadim MK, Fullinwider J, Saracino G, Francoz C, Sartin R, Trotter JF, Asrani SK. Estimating Glomerular Filtration Rate in Cirrhosis Using Creatinine-Based and Cystatin C-Based Equations: Systematic Review and Meta-Analysis. Liver Transpl 2021; 27:1538-1552. [PMID: 34143570 DOI: 10.1002/lt.26216] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/20/2021] [Accepted: 06/07/2021] [Indexed: 12/12/2022]
Abstract
Accurate estimation of kidney function in cirrhosis is crucial for prognosis and decisions regarding dual-organ transplantation. We performed a systematic review/meta-analysis to assess the performance of creatinine-based and cystatin C (CysC)-based eGFR equations compared with measured GFR (mGFR) in patients with cirrhosis. A total of 25 studies (n = 4565, 52.0 years, 37.0% women) comprising 18 equations met the inclusion criteria. In all GFR equations, the creatinine-based equations overestimated GFR (standardized mean difference, SMD, 0.51; 95% confidence interval [CI], 0.31-0.71) and CysC-based equations underestimated GFR (SMD, -0.3; 95% CI, -0.60 to -0.02). Equations based on both creatinine and CysC were the least biased (SMD, -0.14; 95% CI, -0.46 to 0.18). Chronic kidney disease-Epi-serum creatinine-CysC (CESC) was the least biased but had low precision and underestimated GFR by -3.6 mL/minute/1.73 m2 (95% CI, -17.4 to 10.3). All equations significantly overestimated GFR (+21.7 mL/minute/1.73 m2 ; 95% CI, 17.7-25.7) at GFR <60 mL/minute/1.73 m2 ; of these, chronic kidney disease-Epi-CysC (10.3 mL/minute/1.73 m2 ; 95% CI, 2.1-18.4) and GFR Assessment in Liver Disease (12.6 mL/minute/1.73 m2 ; 95% CI, 7.2-18.0) were the least biased followed by Royal Free Hospital (15 mL/minute/1.73 m2 ; 95% CI, 5.5-24.6) and Modification of Diet in Renal Disease 6 (15.7 mL/minute/1.73 m2 ; 95% CI, 10.6-20.8); however, there was an overlap in the precision of estimates, and the studies were limited. In ascites, overestimation of GFR was common (+8.3 mL/minute/1.73 m2 ; 95% CI, -3.1 to 19.7). However, overestimation of GFR by 10 to 20 mL/minute/1.73m2 is common in patients with cirrhosis with most equations in ascites and/or kidney dysfunction. A tailored approach is required especially for decisions regarding dual-organ transplantation.
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Affiliation(s)
- Prianka Singapura
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX
| | - Tsung-Wei Ma
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX
| | - Naveed Sarmast
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX
| | - Stevan A Gonzalez
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX
| | - François Durand
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, University of Paris, Paris, France
| | - Rakhi Maiwall
- Institute of Liver & Biliary Sciences, New Delhi, India
| | - Mitra K Nadim
- Division of Nephrology, University of Southern California, Los Angeles, CA
| | - John Fullinwider
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX
| | - Giovanna Saracino
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX
| | - Claire Francoz
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, University of Paris, Paris, France
| | - Rebecca Sartin
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX
| | - James F Trotter
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX
| | - Sumeet K Asrani
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX
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30
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Dong V, Nadim MK, Karvellas CJ. Post-Liver Transplant Acute Kidney Injury. Liver Transpl 2021; 27:1653-1664. [PMID: 33963666 DOI: 10.1002/lt.26094] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/19/2021] [Accepted: 04/26/2021] [Indexed: 12/13/2022]
Abstract
Acute kidney injury (AKI) is a common condition following liver transplantation (LT). It negatively impacts patient outcomes by increasing the chances of developing chronic kidney disease and reducing graft and patient survival rates. Multiple definitions of AKI have been proposed and used throughout the years, with the International Club of Ascites definition being the most widely now used for patients with cirrhosis. Multiple factors are associated with the development of post-LT AKI and can be categorized into pre-LT comorbidities, donor and recipient characteristics, operative factors, and post-LT factors. Many of these factors can be optimized in an attempt to minimize the risk of AKI occurring and to improve renal function if AKI is already present. A special consideration during the post-LT phase is needed for immunosuppression as certain immunosuppressive medications can be nephrotoxic. The calcineurin inhibitor tacrolimus (TAC) is the mainstay of immunosuppression but can result in AKI. Several strategies including use of the monoclonoal antibody basilixamab to allow for delayed initiation of tacrolimus therapy and minimization through combination and minimization or elimination of TAC through combination with mycophenolate mofetil or mammalian target of rapamycin inhibitors have been implemented to reverse and avoid AKI in the post-LT setting. Renal replacement therapy may ultimately be required to support patients until recovery of AKI after LT. Overall, by improving renal function in post-LT patients with AKI, outcomes can be improved.
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Affiliation(s)
- Victor Dong
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Alberta, Canada.,Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, University of Southern California, Los Angeles, CA
| | - Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada.,Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
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31
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Westphal SG, Langewisch ED, Miles CD. Current State of Multiorgan Transplantation and Implications for Future Practice and Policy. Adv Chronic Kidney Dis 2021; 28:561-569. [PMID: 35367024 DOI: 10.1053/j.ackd.2021.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/17/2021] [Accepted: 09/28/2021] [Indexed: 12/07/2022]
Abstract
The incidence of kidney dysfunction has increased in liver transplant and heart transplant candidates, reflecting a changing patient population and allocation policies that prioritize the most urgent candidates. A higher burden of pretransplant kidney dysfunction has resulted in a substantial rise in the utilization of multiorgan transplantation (MOT). Owing to a shortage of available deceased donor kidneys, the increased use of MOT has the potential to disadvantage kidney-alone transplant candidates, as current allocation policies generally provide priority for MOT candidates above all kidney-alone transplant candidates. In this review, the implications of kidney disease in liver transplant and heart transplant candidates is reviewed, and current policies used to allocate organs are discussed. Important ethical considerations pertaining to MOT allocation are examined, and future policy modifications that may improve both equity and utility in MOT policy are considered.
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32
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Polyak A, Kuo A, Sundaram V. Evolution of liver transplant organ allocation policy: Current limitations and future directions. World J Hepatol 2021; 13:830-839. [PMID: 34552690 PMCID: PMC8422916 DOI: 10.4254/wjh.v13.i8.830] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 06/22/2021] [Accepted: 07/22/2021] [Indexed: 02/06/2023] Open
Abstract
Since the adoption of the model for end-stage liver disease (MELD) score for organ allocation in 2002, numerous changes to the system of liver allocation and distribution have been made with the goal of decreasing waitlist mortality and minimizing geographic variability in median MELD score at time of transplant without worsening post-transplant outcomes. These changes include the creation and adoption of the MELD-Na score for allocation, Regional Share 15, Regional Share for Status 1, Regional Share 35/National Share 15, and, most recently, the Acuity Circles Distribution Model. However, geographic differences in median MELD at time of transplant remain as well as limits to the MELD score for allocation, as etiology of liver disease and need for transplant changes. Acute-on-chronic liver failure (ACLF) is a subset of liver failure where prevalence is rising and has been shown to have an increased mortality rate and need for transplantation that is under-demonstrated by the MELD score. This underscores the limitations of the MELD score and raises the question of whether MELD is the most accurate, objective allocation system. Alternatives to the MELD score have been proposed and studied, however MELD score remains as the current system used for allocation. This review highlights policy changes since the adoption of the MELD score, addresses limitations of the MELD score, reviews proposed alternatives to MELD, and examines the specific implications of these changes and alternatives for ACLF.
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Affiliation(s)
- Alexander Polyak
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Alexander Kuo
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Vinay Sundaram
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
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33
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Ebert N, Bevc S, Bökenkamp A, Gaillard F, Hornum M, Jager KJ, Mariat C, Eriksen BO, Palsson R, Rule AD, van Londen M, White C, Schaeffner E. Assessment of kidney function: clinical indications for measured GFR. Clin Kidney J 2021; 14:1861-1870. [PMID: 34345408 PMCID: PMC8323140 DOI: 10.1093/ckj/sfab042] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Indexed: 12/18/2022] Open
Abstract
In the vast majority of cases, glomerular filtration rate (GFR) is estimated using serum creatinine, which is highly influenced by age, sex, muscle mass, body composition, severe chronic illness and many other factors. This often leads to misclassification of patients or potentially puts patients at risk for inappropriate clinical decisions. Possible solutions are the use of cystatin C as an alternative endogenous marker or performing direct measurement of GFR using an exogenous marker such as iohexol. The purpose of this review is to highlight clinical scenarios and conditions such as extreme body composition, Black race, disagreement between creatinine- and cystatin C-based estimated GFR (eGFR), drug dosing, liver cirrhosis, advanced chronic kidney disease and the transition to kidney replacement therapy, non-kidney solid organ transplant recipients and living kidney donors where creatinine-based GFR estimation may be invalid. In contrast to the majority of literature on measured GFR (mGFR), this review does not include aspects of mGFR for research or public health settings but aims to reach practicing clinicians and raise their understanding of the substantial limitations of creatinine. While including cystatin C as a renal biomarker in GFR estimating equations has been shown to increase the accuracy of the GFR estimate, there are also limitations to eGFR based on cystatin C alone or the combination of creatinine and cystatin C in the clinical scenarios described above that can be overcome by measuring GFR with an exogenous marker. We acknowledge that mGFR is not readily available in many centres but hope that this review will highlight and promote the expansion of kidney function diagnostics using standardized mGFR procedures as an important milestone towards more accurate and personalized medicine.
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Affiliation(s)
- Natalie Ebert
- Institute of Public Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastjan Bevc
- Department of Nephrology, Faculty of Medicine, Clinic for Internal Medicine, University Medical Center Maribor, University of Maribor, Maribor, Slovenia
| | - Arend Bökenkamp
- Department of Pediatric Nephrology, Amsterdam University Medical Center, Emma Kinderziekenhuis, Amsterdam, The Netherlands
| | - Francois Gaillard
- AP-HP, Hôpital Bichat, Service de Néphrologie, Université de Paris, INSERM U1149, Paris, France
| | - Mads Hornum
- Department of Nephrology, Rigshospitalet and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kitty J Jager
- Department of Medical Informatics, ERA-EDTA Registry, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Bjørn Odvar Eriksen
- Metabolic and Renal Research Group, UiT The Arctic University of Norway, Tromsø, Norway
| | - Runolfur Palsson
- Internal Medicine Services, Division of Nephrology, Landspitali–The National University Hospital of Iceland and Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Marco van Londen
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Christine White
- Department of Medicine, Division of Nephrology, Queen’s University, Kingston, Canada
| | - Elke Schaeffner
- Institute of Public Health, Charité Universitätsmedizin Berlin, Berlin, Germany
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Morelli MC, Rendina M, La Manna G, Alessandria C, Pasulo L, Lenci I, Bhoori S, Messa P, Biancone L, Gesualdo L, Russo FP, Petta S, Burra P. Position paper on liver and kidney diseases from the Italian Association for the Study of Liver (AISF), in collaboration with the Italian Society of Nephrology (SIN). Dig Liver Dis 2021; 53 Suppl 2:S49-S86. [PMID: 34074490 DOI: 10.1016/j.dld.2021.03.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/31/2021] [Accepted: 03/31/2021] [Indexed: 02/07/2023]
Abstract
Liver and kidney are strictly connected in a reciprocal manner, in both the physiological and pathological condition. The Italian Association for the Study of Liver, in collaboration with the Italian Society of Nephrology, with this position paper aims to provide an up-to-date overview on the principal relationships between these two important organs. A panel of well-recognized international expert hepatologists and nephrologists identified five relevant topics: 1) The diagnosis of kidney damage in patients with chronic liver disease; 2) Acute kidney injury in liver cirrhosis; 3) Association between chronic liver disease and chronic kidney disease; 4) Kidney damage according to different etiology of liver disease; 5) Polycystic kidney and liver disease. The discussion process started with a review of the literature relating to each of the five major topics and clinical questions and related statements were subsequently formulated. The quality of evidence and strength of recommendations were graded according to the GRADE system. The statements presented here highlight the importance of strong collaboration between hepatologists and nephrologists for the management of critically ill patients, such as those with combined liver and kidney impairment.
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Affiliation(s)
- Maria Cristina Morelli
- Internal Medicine Unit for the treatment of Severe Organ Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy, Via Albertoni 15, 40138, Bologna, Italy
| | - Maria Rendina
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Policlinic Hospital, Piazza G. Cesare 11, 70124, Bari, Italy
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Torino, Corso Bramante 88, 10126, Torino, Italy
| | - Luisa Pasulo
- Gastroenterology and Transplant Hepatology, "Papa Giovanni XXIII" Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Ilaria Lenci
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome Viale Oxford 81, 00133, Rome, Italy
| | - Sherrie Bhoori
- Hepatology and Hepato-Pancreatic-Biliary Surgery and Liver Transplantation, Fondazione IRCCS, Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133, Milan, Italy
| | - Piergiorgio Messa
- Unit of Nephrology, Università degli Studi di Milano, Via Commenda 15, 20122, Milano, Italy; Nephrology, Dialysis and Renal Transplant Unit-Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Commenda 15, 20122 Milano, Italy
| | - Luigi Biancone
- Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città Della Salute e della Scienza Hospital, University of Turin, Corso Bramante, 88-10126, Turin, Italy
| | - Loreto Gesualdo
- Nephrology Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, Università degli Studi di Bari "Aldo Moro", Piazza G. Cesare 11, 70124, Bari, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, PROMISE, University of Palermo, Piazza delle Cliniche, 2 90127, Palermo, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy.
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Durand F, Roux O, Weiss E, Francoz C. Acute-on-chronic liver failure: Where do we stand? Liver Int 2021; 41 Suppl 1:128-136. [PMID: 34155793 DOI: 10.1111/liv.14855] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/19/2021] [Indexed: 12/12/2022]
Abstract
Acute-on-chronic liver failure (ACLF) is defined by the rapid development of organ(s) failure(s) associated with high rates of early (28-day) mortality in patients with cirrhosis. ACLF has been categorized into three grades of increasing severity according to the nature and number of organ failures. In patients with grade 3 ACLF, 28-day mortality is >70%. While the definition of ACLF has been endorsed by European scientific societies, North American and Asian Pacific associations have proposed alternative definitions. A prognostic score called the CLIF-C ACLF score provides a more precise assessment of the prognosis of patients with ACLF. Although bacterial infections and variceal bleeding are common precipitating factors, no precipitating factor can be identified in almost 60% of patients with ACLF. There is increasing evidence that cirrhosis is a condition characterized by a systemic inflammatory state and occult infections or translocation of bacteria or bacterial products from the lumen of the GUT to the systemic circulation which could play a role in the development of ACLF. Simple and readily available variables to predict the occurrence of ACLF in patients with cirrhosis have been identified and high-risk patients need careful management. Whether prolonged administration of statins, rifaximin or albumin can prevent ACLF requires further study. Patients with organ(s) failure(s) may needed to be admitted to the ICU and there should be no hesitation in admitting patients with cirrhosis to the ICU. No benefit to survival was observed with albumin dialysis and rescue transplantation is the best option in the most severe patients. One-year post-transplant survival rates exceeding 70%-75% have been reported, including in patients with grade 3 ACLF but these patients were highly selected. Criteria have been proposed to define futile transplantation (too ill to be transplanted), but these criteria need to be refined to include age, comorbidities and frailty in addition to markers of disease severity.
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Affiliation(s)
- François Durand
- Hepatology & Liver Intensive Care Hospital Beaujon, Clichy, France.,INSERM U1149, Clichy, France.,University of Paris, Clichy, France
| | - Olivier Roux
- Hepatology & Liver Intensive Care Hospital Beaujon, Clichy, France
| | - Emmanuel Weiss
- INSERM U1149, Clichy, France.,Anesthesiology and Intensive Care, Clichy, France
| | - Claire Francoz
- Hepatology & Liver Intensive Care Hospital Beaujon, Clichy, France.,INSERM U1149, Clichy, France
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The Performance of Equations That Estimate Glomerular Filtration Rate against Measured Urinary Creatinine Clearance in Critically Ill Patients. Crit Care Res Pract 2021; 2021:5520653. [PMID: 34055406 PMCID: PMC8149233 DOI: 10.1155/2021/5520653] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/05/2021] [Indexed: 12/29/2022] Open
Abstract
The performance of glomerular filtration rate- (GFR-) estimating equations was studied against creatinine clearance measured by 24-hour urine collection (CrCl24h-urine) in critically ill patients. Methods. In this substudy of the PermiT trial (https://clinicaltrials.gov/ct2/show/ISRCTN68144998), patients from King Abdulaziz Medical City-Riyadh who had CrCl24h-urine were included. We estimated GFR using Cockroft–Gault (CG), modification of diet in renal disease study (MDRD), chronic kidney disease epidemiology collaboration (CKD-EPI), and Jelliffe equations. For the CG equation, we entered the actual weight in one calculation (CGactual-wt), and if BMI ≥30 kg/m2, we entered the ideal body weight (CGideal-wt) and the adjusted body weight (CGadjusted-wt) in two calculations. We calculated the MDRD equation based on 4 (MDRD-4) and 6 variables (MDRD-6). The performance of these equations was assessed by different ways including Spearman correlation, bias (difference between estimated GFR and CrCl24h-urine), precision (standard deviation of bias), and Bland–Altman plot analysis. Results. The cohort consisted of 237 patients (age 45 ± 20 years, males 75%, mechanically ventilated 99% with serum creatinine 101 ± 94 µmol/L and CrCl24h-urine 108 ± 69 ml/min/1.73 m2). The correlations between the different equations and CrCl24h-urine were modest (r: 0.62 to 0.79; p < 0.0001). Bias was statistically significant for CGactual-wt (21 ml/min), CGadjusted-wt (12 ml/min), and MDRD-6 (-10 ml/min) equations. Precision ranged from 46 to 54 ml/min. The sensitivity of equations to correctly classify CrCl24h-urine 30–59.9 ml/min/1.73 m2 was 17.2% for CGactual-wt, 30.0% for CGideal-wt, 31.0% for CGadjusted-wt, 31.0% for MDRD-4, 39.1% for MDRD-6, 13.8% for CKD-EPI, and 34.5% for Jelliffe equation. Conclusions. Commonly used GFR-estimating equations had limited ability to properly estimate CrCl24h-urine and to correctly classify GFR into clinically relevant ranges that usually determine dosing of medications.
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Allegretti AS, Parada XV, Endres P, Zhao S, Krinsky S, St. Hillien SA, Kalim S, Nigwekar SU, Flood JG, Nixon A, Simonetto DA, Juncos LA, Karakala N, Wadei HM, Regner KR, Belcher JM, Nadim MK, Garcia-Tsao G, Velez JCQ, Parikh SM, Chung RT. Urinary NGAL as a Diagnostic and Prognostic Marker for Acute Kidney Injury in Cirrhosis: A Prospective Study. Clin Transl Gastroenterol 2021; 12:e00359. [PMID: 33979307 PMCID: PMC8116001 DOI: 10.14309/ctg.0000000000000359] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/05/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Urinary neutrophil gelatinase-associated lipocalin (NGAL) has shown promise in differentiating acute tubular necrosis (ATN) from other types of acute kidney injuries (AKIs) in cirrhosis, particularly hepatorenal syndrome (HRS). However, NGAL is not currently available in clinical practice in North America. METHODS Urinary NGAL was measured in a prospective cohort of 213 US hospitalized patients with decompensated cirrhosis (161 with AKI and 52 reference patients without AKI). NGAL was assessed for its ability to discriminate ATN from non-ATN AKI and to predict 90-day outcomes. RESULTS Among patients with AKI, 57 (35%) had prerenal AKI, 55 (34%) had HRS, and 49 (30%) had ATN, with a median serum creatinine of 2.0 (interquartile range 1.5, 3.0) mg/dL at enrollment. At an optimal cutpoint of 244 μg/g creatinine, NGAL distinguished ATN (344 [132, 1,429] μg/g creatinine) from prerenal AKI (45 [0, 154] μg/g) or HRS (110 [50, 393] μg/g; P < 0.001), with a C statistic of 0.762 (95% confidence interval 0.682, 0.842). By 90 days, 71 of 213 patients (33%) died. Higher median NGAL was associated with death (159 [50, 865] vs 58 [0, 191] μg/g; P < 0.001). In adjusted and unadjusted analysis, NGAL significantly predicted 90-day transplant-free survival (P < 0.05 for all Cox models) and outperformed Model for End-Stage Liver Disease score by C statistic (0.697 vs 0.686; P = 0.04), net reclassification index (37%; P = 0.008), and integrated discrimination increment (2.7%; P = 0.02). DISCUSSION NGAL differentiates the type of AKI in cirrhosis and may improve prediction of mortality; therefore, it holds potential to affect management of AKI in cirrhosis.
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Affiliation(s)
- Andrew S. Allegretti
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - Xavier Vela Parada
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - Paul Endres
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - Sophia Zhao
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - Scott Krinsky
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - Shelsea A. St. Hillien
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - Sahir Kalim
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - Sagar U. Nigwekar
- Division of Nephrology, Department of Medicine,
Massachusetts General Hospital, Boston, Massachusetts,
USA
| | - James G. Flood
- Department of Pathology, Massachusetts General
Hospital, Boston, Massachusetts, USA;
| | - Andrea Nixon
- Department of Pathology, Massachusetts General
Hospital, Boston, Massachusetts, USA;
| | - Douglas A. Simonetto
- Division of Gastroenterology and Hepatology, Mayo
Clinic, Rochester, Minnesota, USA;
| | - Luis A. Juncos
- Department of Medicine, University of Arkansas for
Medical Sciences, Central Arkansas Veterans Healthcare System, Little Rock,
Arkansas, USA;
| | - Nithin Karakala
- Department of Medicine, University of Arkansas for
Medical Sciences, Central Arkansas Veterans Healthcare System, Little Rock,
Arkansas, USA;
| | - Hani M. Wadei
- Department of Transplantation, Mayo Clinic,
Jacksonville, Florida, USA;
| | - Kevin R. Regner
- Division of Nephrology, Medical College of Wisconsin,
Milwaukee, Wisconsin, USA;
| | - Justin M. Belcher
- Section of Nephrology, Yale University School of
Medicine, New Haven, Connecticut, USA and Section of Nephrology, VA-Connecticut
Healthcare System, West Haven, Connecticut, USA;
| | - Mitra K. Nadim
- Division of Nephrology and Hypertension, Keck School
of Medicine, University of Southern California, Los Angeles, California,
USA;
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, VA-Connecticut
Healthcare System, West Haven, Connecticut, USA;
| | | | - Samir M. Parikh
- Division of Nephrology, Department of Medicine,
Beth Israel Deaconess Medical Center, Boston, Massachusetts,
USA;
| | - Raymond T. Chung
- Liver Center and Gastrointestinal Division,
Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts,
USA.
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Sanchez LO, Francoz C. Global strategy for the diagnosis and management of acute kidney injury in patients with liver cirrhosis. United European Gastroenterol J 2021; 9:220-228. [PMID: 33337286 PMCID: PMC8259425 DOI: 10.1177/2050640620980713] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 11/18/2021] [Indexed: 12/18/2022] Open
Abstract
Acute kidney injury (AKI) is a clinical syndrome that complicates the course and worsens clinical outcomes in patients with chronic liver diseases. It is a common complication in hospitalised patients with liver cirrhosis, especially those with decompensated cirrhosis, associated with a high mortality rate. Considering its impact on patient prognosis, efforts should be made to diagnose and tailor therapeutic interventions for AKI at an early stage. In the past decade, a significant progress has been made to understand the key events and define major prognostic factors for the onset and progression of AKI in the cirrhotic population leading hepatologists to redefine the classic definition of hepatorenal syndrome and renal failure in this specific population.
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Affiliation(s)
- Lukas Otero Sanchez
- Department of Gastroenterology, Hepatopancreatology and Digestive OncologyUniversité Libre de BruxellesBrusselsBelgium
- Belgium Laboratory of Experimental Gastroenterology, Université Libre de BruxellesBrusselsBelgium
| | - Claire Francoz
- Department of Hepatology and Liver Intensive CareHospital BeaujonClichyFrance
- INSERM U1149Centre de Recherche sur L'InflammationParisFrance
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Tonon M, Rosi S, Gambino CG, Piano S, Calvino V, Romano A, Martini A, Pontisso P, Angeli P. Natural history of acute kidney disease in patients with cirrhosis. J Hepatol 2021; 74:578-583. [PMID: 32918956 DOI: 10.1016/j.jhep.2020.08.037] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS In 2012, the KDIGO group proposed new definitions for acute kidney injury (AKI), acute kidney disease (AKD) and chronic kidney disease (CKD). According to the definition adapted by the International Club of Ascites, AKI has been extensively investigated in patients with cirrhosis. On the contrary, there are currently no data on the epidemiology and clinical outcomes associated with AKD. The aim of the study was to assess the prevalence and the impact of AKD on the clinical course and survival of patients with cirrhosis. METHODS A total of 272 consecutive patients with cirrhosis attending our outpatient clinic were included in the study. Clinical and laboratory data were collected at inclusion. Patients were followed-up until death, liver transplant or the end of follow-up. RESULTS During follow-up, 80 patients developed AKD (29.4%). Forty-two (52.5%) recovered from the first episode of AKD and 26 maintained a normal renal function up to the end of follow-up. Sixteen patients developed a second episode of AKD. Globally, 36 patients (45.0%) died with AKD. Finally, AKD progressed to CKD in 11 patients (13.8%). The 5-year survival rate was significantly lower in patients who developed AKD than in those who did not (34.8% vs. 88.8%, p <0.001). The 5-year rates of complications of cirrhosis and of hospitalizations were also higher in patients with AKD than in those without AKD. CONCLUSIONS AKD is frequent in patients with cirrhosis. It can be reversible, but it may recur and progress to CKD. AKD has a very negative impact on morbidity and mortality in patients with cirrhosis. LAY SUMMARY Renal impairment has a very negative impact on patients with cirrhosis. Renal impairment seems to be characterized by a very dynamic course, which is defined according to renal function and length of the impairment as acute kidney injury, acute kidney disease and chronic kidney disease. The role of acute kidney disease is currently unknown. Our study shows for the first time that acute kidney disease is frequent in patients with cirrhosis and has a very negative impact on survival.
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Affiliation(s)
- Marta Tonon
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Silvia Rosi
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Carmine Gabriele Gambino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Valeria Calvino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Antonietta Romano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Andrea Martini
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Patrizia Pontisso
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy.
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Bari K, Sharma P. Optimizing the Selection of Patients for Simultaneous Liver-Kidney Transplant. Clin Liver Dis 2021; 25:89-102. [PMID: 33978585 DOI: 10.1016/j.cld.2020.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Simultaneous liver-kidney transplantation has increased significantly in the Model for End Stage Liver Disease era. The transplantation policy has evolved significantly since the implementation of allocation based on the Model for End Stage Liver Disease. Current policy takes into account the medical eligibility criteria for simultaneous liver-kidney transplantation listing. It also provides a safety net option and prioritizes kidney transplant after liver transplant recipients who are unlikely to recover their renal function within 60 to 365 days after liver transplant alone. This review seeks to understand the underlying challenges in carefully selecting the candidates while optimizing the patient selection.
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Affiliation(s)
- Khurram Bari
- Division of Gastroenterology and Hepatology, University of Cincinnati, 231 Albert Sabin Way, ML 0595, MSB 7259, Cincinnati, OH 45267, USA
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, 3912 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Allegretti AS, Solà E, Ginès P. Clinical Application of Kidney Biomarkers in Cirrhosis. Am J Kidney Dis 2020; 76:710-719. [DOI: 10.1053/j.ajkd.2020.03.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/09/2020] [Indexed: 12/14/2022]
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The Eye as a Non-Invasive Window to the Microcirculation in Liver Cirrhosis: A Prospective Pilot Study. J Clin Med 2020; 9:jcm9103332. [PMID: 33080821 PMCID: PMC7603064 DOI: 10.3390/jcm9103332] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 09/30/2020] [Accepted: 10/13/2020] [Indexed: 12/19/2022] Open
Abstract
Microcirculatory dysfunction is associated with organ failure, poor response to vasoactive drugs and increased mortality in cirrhosis, but monitoring techniques are not established. We hypothesized that the chorioretinal structures of the eye could be visualized as a non-invasive proxy of the systemic microvasculature in cirrhosis and would correlate with renal dysfunction. Optical Coherence Tomography (OCT) was performed to image the retina in n = 55 cirrhosis patients being assessed for liver transplantation. OCT parameters were compared with established cohorts of age- and sex-matched healthy volunteers (HV) and patients with chronic kidney disease (CKD). Retinal thickness, macular volume and choroidal thickness were significantly reduced relative to HV and comparable to CKD patients (macular volume: HV vs. cirrhosis mean difference 0.44 mm3 (95% CI 0.26–0.61), p ≤ 0.0001). Reduced retinal thickness and macular volume correlated with renal dysfunction in cirrhosis (macular volume vs. MDRD-6 eGFR r = 0.40, p = 0.006). Retinal changes had resolved substantially 6 weeks following transplantation. There was an inverse association between choroidal thickness and circulating markers of endothelial dysfunction (endothelin-1 r = −0.49, p ≤ 0.001; von Willebrand factor r = −0.32, p ≤ 0.05). Retinal OCT may represent a non-invasive window to the microcirculation in cirrhosis and a dynamic measure of renal and endothelial dysfunction. Validation in different cirrhosis populations is now required.
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Kumar U, Kumar R, Jha SK, Jha AK, Dayal VM, Kumar A. Short-term mortality in patients with cirrhosis of the liver and acute kidney injury: A prospective observational study. Indian J Gastroenterol 2020; 39:457-464. [PMID: 33175368 DOI: 10.1007/s12664-020-01086-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 08/03/2020] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Uday Kumar
- Patna Medical College, Patna 800 001, India
| | - Ravikant Kumar
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, 800 014, India.
| | - Sanjeev Kumar Jha
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, 800 014, India
| | - Ashish Kumar Jha
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, 800 014, India
| | - Vishwa Mohan Dayal
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, 800 014, India
| | - Amarendra Kumar
- Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna, 800 014, India
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Renal disease in the allograft recipient. Best Pract Res Clin Gastroenterol 2020; 46-47:101690. [PMID: 33158468 DOI: 10.1016/j.bpg.2020.101690] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 01/31/2023]
Abstract
Chronic renal failure after liver transplantation (LT) is significantly more frequent than after lung or heart transplantation and it results in an increased short and long-term mortality. Renal impairment may occur before LT (functional or due to preexisting parenchymal kidney disease), in the peri-operative period or later after LT. The number of patients with renal failure after LT has increased due to the liver allocation based on MELD and to the more liberal use of higher risk grafts. Calcineurin inhibitor (CNI) nephrotoxicity is the most important cause of renal dysfunction but is a modifiable factor. Strategy to prevent CNI-associated nephrotoxicity is post-op CNI minimization by induction therapy and reduced dose and/or delayed introduction of CNI in combination with mycophenolate mofetil (MMF) or everolimus with no penalty in term of rejection. With everolimus, usually started one month after LT, a drastic minimization of CNI is possible and this results in superior kidney function until at least 3 years follow up. At the moment of renal impairment a drastic reduction of CNI dose together with the introduction of MMF results in an improvement in GFR at 6 to 2 years with a low rate of acute rejection. However, secondary prevention fails to normalize renal function in most of the patients once e GFR <60 ml/min/1.73m2ml.
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45
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Francoz C. Acute kidney injury in cirrhosis: An immediate threat but also a ticking time bomb. J Hepatol 2020; 72:1043-1045. [PMID: 32197803 DOI: 10.1016/j.jhep.2020.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/16/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Claire Francoz
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, France, INSERM U1149, Centre de Recherche sur l'Inflammation, Paris, France.
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46
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Cullaro G, Verna EC, Lee BP, Lai JC. Chronic Kidney Disease in Liver Transplant Candidates: A Rising Burden Impacting Post-Liver Transplant Outcomes. Liver Transpl 2020; 26:498-506. [PMID: 31785069 PMCID: PMC8056970 DOI: 10.1002/lt.25694] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 11/12/2019] [Indexed: 12/21/2022]
Abstract
The burden of chronic kidney disease (CKD) is rising among patients with cirrhosis, though it is not known what impact this has had on outcomes after liver transplantation (LT). All patients listed for LT in the United States between 2002 and 2017 were analyzed, excluding those listed with Model for End-Stage Liver Disease (MELD) exceptions. The primary outcome was post-LT mortality. We defined pre-LT CKD as an estimated glomerular filtration rate <60 mL/minute for 90 days or ≥42 days of hemodialysis. Cox regression determined the association between pre-LT CKD and post-LT mortality. Of 78,640 LT candidates, the proportion with CKD among LT recipients increased from 7.8% in 2002 to 14.6% in 2017 (test for trend, P < 0.001). Among the 39,719 LT recipients, pre-LT CKD was significantly associated with post-LT mortality (hazard ratio [HR], 1.16; P < 0.001) even after adjusting for donor risk index (DRI), age, MELD, etiology, hepatic encephalopathy, simultaneous liver-kidney transplantation (SLKT), and diabetes. There was no mediating influence of SLKT on the effect of pre-LT CKD on post-LT survival (P > 0.05). Therefore, pre-LT CKD has a deleterious impact on post-LT outcomes, which is an impact that is not mediated through SLKT. These findings highlight the need for the identification of CKD when preventative measures are possible.
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Affiliation(s)
- Giuseppe Cullaro
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Brian P. Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, CA, USA
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47
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Luis-Lima S, Escamilla-Cabrera B, Negrín-Mena N, Estupiñán S, Delgado-Mallén P, Marrero-Miranda D, González-Rinne A, Miquel-Rodríguez R, Cobo-Caso MÁ, Hernández-Guerra M, Oramas J, Batista N, Aldea-Perona A, Jorge-Pérez P, González-Alayón C, Moreno-Sanfiel M, González-Rodríguez JA, Henríquez L, Alonso-Pescoso R, Díaz-Martín L, González-Rinne F, Lavín-Gómez BA, Galindo-Hernández J, Sánchez-Gallego M, González-Delgado A, Jiménez-Sosa A, Torres A, Porrini E. Chronic kidney disease staging with cystatin C or creatinine-based formulas: flipping the coin. Nephrol Dial Transplant 2020; 34:287-294. [PMID: 29762739 DOI: 10.1093/ndt/gfy086] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 03/09/2018] [Indexed: 11/12/2022] Open
Abstract
Background Chronic kidney disease (CKD) affects 10-13% of the population worldwide. CKD classification stratifies patients in five stages of risk for progressive renal disease based on estimated glomerular filtration rate (eGFR) by formulas and albuminuria. However, the reliability of formulas to reflect real renal function is a matter of debate. The effect of the error of formulas in the CKD classification is unclear, particularly for cystatin C-based equations. Methods We evaluated the reliability of a large number of cystatin C and/or creatinine-based formulas in the definition of the stages of CKD in 882 subjects with different clinical situations over a wide range of glomerular filtration rates (GFRs) (4.2-173.7 mL/min). Results Misclassification was a constant for all 61 formulas evaluated and averaged 50% for creatinine-based and 35% for cystatin C-based equations. Most of the cases were misclassified as one stage higher or lower. However, in 10% of the subjects, one stage was skipped and patients were classified two stages above or below their real stage. No clinically relevant improvement was observed with cystatin C-based formulas compared with those based on creatinine. Conclusions The error in the classification of CKD stages by formulas was extremely common. Our study questions the reliability of both cystatin C and creatinine-based formulas to correctly classify CKD stages. Thus the correct classification of CKD stages based on estimated GFR is a matter of chance. This is a strong limitation in evaluating the severity of renal disease, the risk for progression and the evolution of renal dysfunction over time.
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Affiliation(s)
- Sergio Luis-Lima
- Research Unit Department, Hospital Universitario de Canarias, Tenerife, Spain
| | | | - Natalia Negrín-Mena
- Research Unit Department, Hospital Universitario de Canarias, Tenerife, Spain
| | - Sara Estupiñán
- Nephrology Department, Hospital Universitario de Canarias, Tenerife, Spain
| | | | | | - Ana González-Rinne
- Nephrology Department, Hospital Universitario de Canarias, Tenerife, Spain
| | | | | | | | - Juana Oramas
- Oncology Department, Hospital Universitario de Canarias, Tenerife, Spain
| | - Norberto Batista
- Oncology Department, Hospital Universitario de Canarias, Tenerife, Spain
| | - Ana Aldea-Perona
- Research Unit Department, Hospital Universitario de Canarias, Tenerife, Spain
| | - Pablo Jorge-Pérez
- Cardiology Department, Hospital Universitario de Canarias, Tenerife, Spain
| | | | | | | | - Laura Henríquez
- Endocrinology Department, Hospital Universitario de Canarias, Tenerife, Spain
| | | | - Laura Díaz-Martín
- Research Unit Department, Hospital Universitario de Canarias, Tenerife, Spain
| | | | | | | | | | | | | | - Armando Torres
- Nephrology Department, Hospital Universitario de Canarias, Tenerife, Spain.,Internal Medicine Department, Universidad de La Laguna, Tenerife, Spain
| | - Esteban Porrini
- Internal Medicine Department, Universidad de La Laguna, Tenerife, Spain
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48
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Torner M, Mangal A, Scharnagl H, Jansen C, Praktiknjo M, Queck A, Gu W, Schierwagen R, Lehmann J, Uschner FE, Graf C, Strassburg CP, Fernandez J, Stojakovic T, Woitas R, Trebicka J. Sex specificity of kidney markers to assess prognosis in cirrhotic patients with TIPS. Liver Int 2020; 40:186-193. [PMID: 31448496 DOI: 10.1111/liv.14230] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/18/2019] [Accepted: 08/20/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Renal function assessed by creatinine is a key prognostic factor in cirrhotic patients. However, creatinine is influenced by several factors, rendering interpretation difficult in some situations. This is especially important in early stages of renal dysfunction where renal impairment might not be accompanied by an increase in creatinine. Other parameters, such as cystatin C (CysC) and beta-trace protein (BTP), have been evaluated to fill this gap. However, none of these studies have considered the role of the patient's sex. The present study analysed CysC and BTP to evaluate their prognostic value and differentiate them according to sex. PATIENTS AND METHODS CysC and BTP were measured in 173 transjugular intrahepatic portosystemic shunt (TIPS)-patients from the NEPTUN-STUDY(NCT03628807) and analysed their relationship with mortality and sex. Propensity score for age, MELD, etiology and TIPS indication was used. RESULTS Cystatin C and BTP showed excellent correlations with creatinine values at baseline and follow-up. CysC was an independent predictor of overall mortality (HR = 1.66(1.33-2.06)) with an AUC of 0.75 and identified a cut-off of 1.55 mg/L in the whole cohort. Interestingly, CysC was significantly lower in females, also after propensity score matching. In males, the only independent predictor was the creatinine level (HR = 1.54(1.25-1.58)), while in females CysC levels independently predicted mortality (HR = 3.17(1.34-7.52)). CONCLUSION This study demonstrates for the first time that in TIPS-patients creatinine predicts mortality in males better than in females, whereas CysC is a better predictor of mortality in females. These results may influence future clinical decisions on therapeutic options for example, allocation for liver transplantation in TIPS-patients.
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Affiliation(s)
- Maria Torner
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain.,Liver ICU, Liver Unit, Hospital Clinic y Provencial de Barcelona, Barcelona, Spain
| | - Adjmal Mangal
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Hubert Scharnagl
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Christian Jansen
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | | | - Alexander Queck
- Translational Hepatology, Department of Internal Medicine I, University Clinic Frankfurt, Frankfurt, Germany
| | - Wenyi Gu
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,Translational Hepatology, Department of Internal Medicine I, University Clinic Frankfurt, Frankfurt, Germany.,Department of Gastroenterology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Robert Schierwagen
- Translational Hepatology, Department of Internal Medicine I, University Clinic Frankfurt, Frankfurt, Germany
| | - Jennifer Lehmann
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Frank E Uschner
- Department of Gastroenterology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Christiana Graf
- Department of Gastroenterology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | | | - Javier Fernandez
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,Liver ICU, Liver Unit, Hospital Clinic y Provencial de Barcelona, Barcelona, Spain
| | - Tatjana Stojakovic
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, University Hospital Graz, Graz, Austria
| | - Rainer Woitas
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Jonel Trebicka
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,Department of Gastroenterology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Institute for Bioengineering of Catalonia, Barcelona, Spain
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49
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Godfrey EL, Malik TH, Lai JC, Mindikoglu AL, Galván NTN, Cotton RT, O'Mahony CA, Goss JA, Rana A. The decreasing predictive power of MELD in an era of changing etiology of liver disease. Am J Transplant 2019; 19:3299-3307. [PMID: 31394020 DOI: 10.1111/ajt.15559] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 06/24/2019] [Accepted: 07/19/2019] [Indexed: 01/25/2023]
Abstract
The field of liver transplantation has shifted considerably in the MELD era, including changing allocation, immunosuppression, and liver failure etiologies, as well as better supportive therapies. Our aim was to evaluate the predictive accuracy of the MELD score over time. The United Network for Organ Sharing provided de-identified data on 120 156 patients listed for liver transplant from 2002-2016. The ability of the MELD score to predict 90-day mortality was evaluated by a concordance (C-) statistic and corroborated with competing risk analysis. The MELD score's concordance with 90-day mortality has downtrended from 0.80 in 2003 to 0.70 in 2015. While lab MELD scores at listing and transplant climbed in that interval, score at waitlist death remained steady near 35. Listing age increased from 50 to 54 years. HCV-positive status at listing dropped from 33 to 17%. The concordance of MELD and mortality does not differ with age (>60 = 0.73, <60 = 0.74), but is lower in diseases that are increasing most rapidly-alcoholic liver disease and non-alcoholic fatty liver disease-and higher in those that are declining, particularly in HCV-positive patients (HCV positive = 0.77; negative = 0.73). While MELD still predicts mortality, its accuracy has decreased; changing etiology of disease may contribute.
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Affiliation(s)
- Elizabeth L Godfrey
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Tahir H Malik
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Ayse L Mindikoglu
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Margaret M. and Albert B. Alkek Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
| | - N Thao N Galván
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Ronald T Cotton
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Christine A O'Mahony
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Abbas Rana
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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50
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Bhandari P, Shah Z, Patel K, Patel R. Contrast-induced acute kidney injury following coronary angiography in patients with end-stage liver disease. J Community Hosp Intern Med Perspect 2019; 9:403-409. [PMID: 31723384 PMCID: PMC6830185 DOI: 10.1080/20009666.2019.1661148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/19/2019] [Indexed: 12/28/2022] Open
Abstract
Background: Contrast-induced acute kidney injury (CIAKI) following coronary angiography is frequently observed in the general population. End-stage liver disease (ESLD) patients are at a particularly increased risk for development of CIAKI following coronary angiography due to preexisting renal hypoperfusion. Methods: We performed a retrospective study of 544 consecutive cardiac catheterizations in ESLD patients from December 2003 to May 2013 to calculate the incidence of CIAKI post-coronary angiography and to identify risk factors for CIAKI. CIAKI was defined as a serum creatinine increase of either ≥ 25% or ≥ 0.5 mg/dL from baseline within 72 hours. Multivariable and Cox regression analysis was performed for development of CIAKI and all-cause mortality, respectively. Results: Overall, 179 cases of coronary angiography were included in the final analysis. CIAKI occurred in 23% of patients. All-cause mortality was 52% in the CIAKI group and 37% in the non-CIAKI group, with a mean follow-up of 2.2 ± 3.8 years. Multivariable analysis identified intensive care unit admission (OR 2.72, CI 1.05–7.01, p < 0.05) and baseline estimated glomerular filtration rate (OR 1.02, CI 1.002–1.035, p < 0.05) as independent predictors of CIAKI. Cox regression analysis identified pre-angiography beta-blocker use (HR 2.13, CI 1.04–4.38, p < 0.05), international normalized ratio (HR 1.37, CI 1.05–1.78, p < 0.05) and Mehran risk score (HR 1.13, CI 1.02–1.25, p < 0.05) as independent predictors of all-cause mortality. Conclusions: CIAKI in ESLD patients undergoing coronary angiography occurs at a moderately elevated rate when compared to the general population.
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Affiliation(s)
- Priyanka Bhandari
- Departmant of Internal Medicine, Mount Sinai Elmhurst Hospital, New York, USA
| | - Zeel Shah
- Departmant of Internal Medicine, Mount Sinai Elmhurst Hospital, New York, USA
| | - Kush Patel
- Department of Family Medicine, Southside Northwell Hospital, New York, USA
| | - Ruchir Patel
- Departmant of Internal Medicine, Henry Ford Hospital, Michigan, USA
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