Serum and urinary biomarkers that predict hepatorenal syndrome in patients with advanced cirrhosis

Seeing and Sensing the Hepatorenal Syndrome (HRS): The Growing Role of Ultrasound-Based Techniques as Non-Invasive Tools for the Diagnosis of HRS

More than half of patients hospitalized with liver cirrhosis are dealing with an episode of acute kidney injury; the most severe pattern is hepatorenal syndrome due to its negative prognosis. The main physiopathology mechanisms involve renal vasoconstriction and systemic inflammation. During the last decade, the definition of hepatorenal syndrome changed, but the validated criteria of diagnosis are still based on the serum creatinine level, which is a biomarker with multiple limitations. This is the reason why novel serum and urinary biomarkers have been intensively studied in recent years. Meanwhile, the imaging studies that use shear wave elastography are using renal stiffness as a surrogate for an early diagnosis. In this article, we focus on the physiopathology definition and highlight the novel tools used in the diagnosis of hepatorenal syndrome.

Hepatorenal Syndrome-Novel Insights into Diagnostics and Treatment

Hepatorenal syndrome (HRS) is a disorder associated with cirrhosis and renal impairment, with portal hypertension as its major underlying cause. Moreover, HRS is the third most common cause of acute kidney injury, thus creating a major public health concern. This review summarizes the available information on the pathophysiological implications of HRS. We discuss pathogenesis associated with HRS. Mechanisms such as dysfunction of the circulatory system, bacterial infection, inflammation, impaired renal autoregulation, circulatory, and others, which have been identified as critical pathways for development of HRS, have become easier to diagnose in recent years. Additionally, relatively recently, renal dysfunction biomarkers have been found indicating renal injury, which are involved in the pathophysiology of HRS. This review also summarizes the available information on the management of HRS, focusing on vasoconstrictive drugs, renal replacement therapy, and liver transplant together with currently being investigated novel therapies. Analyzing new discoveries for the underlying causes of this condition assists the general research to improve understanding of the mechanism of pathophysiology and thus prevention of HRS.

Novel prognostic biomarkers in decompensated cirrhosis: a systematic review and meta-analysis

BACKGROUND

Patients with decompensated cirrhosis experience high mortality rates. Current prognostic scores, including the model for end-stage liver disease (MELD), may underperform in settings other than in those they were initially developed. Novel biomarkers have been proposed to improve prognostication accuracy and even to predict development of complications.

METHODS

We performed a systematic review and meta-analysis on novel urine and blood biomarkers and their ability to predict 90-day mortality in patients with decompensated cirrhosis. Secondary outcomes included 28-day and 1-year mortality, and development of acute-on-chronic liver failure, acute kidney injury and other complications. To overcome differences in units, temporal changes in assays and reporting heterogeneity, we used the ratio of means (RoM) as measure of association for assessing strength in predicting outcomes. An RoM>1 implies that the mean biomarker level is higher in those that develop the outcome than in those that do not.

RESULTS

Of 6629 unique references, 103 were included, reporting on 29 different biomarkers, with a total of 31 362 biomarker patients. Most studies were prospective cohorts of hospitalised patients (median Child-Pugh-Turcotte score of 9 and MELD score of 18). The pooled 90-day mortality rate was 0.27 (95% CI 0.24 to 0.29). The RoM for predicting 90-day mortality was highest for interleukin 6 (IL-6) (2.56, 95% CI 2.39 to 2.74), followed by urinary neutrophil gelatinase-associated lipocalin (uNGAL) (2.42, 95% CI 2.20 to 2.66) and copeptin (2.33, 95% CI 2.17 to 2.50). These RoMs were all higher than for MELD (1.44, 95% CI 1.42 to 1.46).

CONCLUSION

Novel biomarkers, including IL-6, uNGAL and copeptin, can probably improve prognostication of patients with decompensated cirrhosis compared with MELD alone.

Establishment and evaluation of an early prediction model of hepatorenal syndrome in patients with decompensated hepatitis B cirrhosis

BACKGROUND AND AIM

In China, hepatorenal syndrome is a serious complication in the decompensated stage of hepatitis B cirrhosis, which requires early clinical intervention, so the early diagnosis of hepatorenal syndrome is crucial. This study establishes a new predictive model based on serum biomarkers for the early diagnosis of hepatorenal syndrome.

METHODS

Patients with decompensated hepatitis B cirrhosis who met the inclusion and exclusion criteria were retrospectively enrolled. Patients were randomly assigned to the training dataset and validation dataset at a 7:3 ratio. Univariate and multivariate logistic regression analyses were used to screen the risk factors for hepatorenal syndrome. The identified risk factors were used to establish and verify a model.

RESULTS

This study included 255 patients with decompensated hepatitis B cirrhosis, including 184 in the training group and 71 in the validation group. The multivariate logistic regression model was established in the training group and verified in the validation group. Logistic regression showed that hemoglobin (OR 0.938, 95% CI 0.908-0.969), total bilirubin (OR 1.014, 95% CI 1.008-1.021) and creatinine (OR 1.079, 95% CI 1.043-1.117) were independent risk factors for hepatorenal syndrome (P < 0.05). These were used to establish the model. In the training group and the validation group, the area under the ROC curve of the nomogram for the diagnosis of hepatorenal syndrome was 0.968 and 0.980, respectively.

CONCLUSION

The three serum biomarkers, including hemoglobin, total bilirubin and creatinine, can be used as independent early predictors of hepatorenal syndrome in patients with decompensated hepatitis B cirrhosis.

Novel Biomarkers of AKI in Cirrhosis

Acute kidney injury (AKI) is a frequent complication in patients with cirrhosis that is associated with poor outcomes and decreased survival. The definition of AKI in cirrhosis is currently based on changes of serum creatinine levels with respect to baseline values. Differential diagnosis of the causes of AKI is of major relevance, considering that some causes of AKI, such as hepatorenal syndrome, have specific treatment options and different prognosis. Prediction of kidney function recovery and patients' survival is also crucial in this patient population to guide clinical decisions. AKI biomarkers in cirrhosis have emerged as a promising tool for differential diagnosis and prognosis in this situation. There are consistent data showing that some urine biomarkers, particularly neutrophil gelatinase-associated lipocalin, may be useful in daily clinical practice for the differential diagnosis of the cause of AKI in cirrhosis. AKI biomarkers may constitute a useful tool for use in differential diagnosis, prognosis of renal function, and survival in patients with cirrhosis. This review focuses on the current state of knowledge and future perspective of novel biomarkers of AKI in cirrhosis.

Hepatorenal Syndrome: A Way for Early and Accurate Diagnosis

BACKGROUND: Hepatorenal syndrome (HRS) is a devastating consequence of liver cirrhosis that is clinically categorized into two subtypes. Acute malfunction of renal role, as measured by an elevation in blood creatinine, significantly underestimates the loss in renal function in cirrhotic individuals; more accurate biomarkers are desperately required in cirrhotic patients. AIM: The present study set out to uncover new biomarkers for the early prediction of AKI in cirrhotic cases. A comprehensive panel of biomarkers was investigated to get a clear insight into the pathogenesis of HRS. PATIENTS AND METHODS: Participants in this study were 70 individuals from the hepatogastroenterology unit of the Theodor Bilharz Research Institute (TBRI). Detailed medical data and a physical examination were recorded. Three groups of patients have been identified; Group 1: 30 cases with compensated liver cirrhosis and normal kidney functions. Group 2: 20 cases with decompensated liver cirrhosis and normal kidney functions. Group 3: 20 cases with decompensated liver cirrhosis proved hepatorenal syndrome Type 2 h. The following biomarkers were detected in serum using the sandwich-ELISA method: Human L-arginine ELISA kit, human neutrophil gelatinase related lipocalin (NGAL), human noradrenaline (NA), human asymmetrical dimethylarginine (ADMA), human symmetric dimethylarginine (SDMA), human nitric oxide (NO), and human renin. RESULTS: There was a highly significant difference between Groups 1 and 2 in NITRIC and ADMA. Significant differences between Groups 2 and 3 in NGAL, noradrenalin, and SDMA were observed. There was a significant difference (Group 2 vs. Group 3) in renin, NITRIC, ADMA, and L-ARGININE. There was highly significant differentiation (Group 2 vs. Group 3) in NGAL, noradrenalin, and SDMA. There was highly significant variation as per odd ratio and confidence interval between (Group 3 vs. Group 2) in NGAL. CONCLUSION: Assessment of renal biomarkers in individuals with decompensated cirrhosis gives critical information on the etiology of AKI. Further, it may aid in the diagnosis and prognosis of AKI. Renin, NITRIC, ADMA, and L-ARGININE could be used as biomarkers to indicate HRS in individuals with advanced cirrhosis.

Role of Novel Kidney Biomarkers in Patients With Cirrhosis and After Liver Transplantation

Acute kidney injury (AKI) and chronic kidney disease (CKD) are important drivers of morbidity and mortality in patients with cirrhosis before and after liver transplantation (LT). In this review, we examine the role of novel kidney biomarkers for early recognition of kidney injury. Studies are limited by lack of reference standards, heterogeneous definitions of outcomes and biomarker cutoffs, and inconsistent diagnostic performance. Overall, a change in biomarker is more relevant than an absolute cutoff. Cystatin C and urinary neutrophil gelatinase-associated lipocalin (uNGAL) are the most studied candidate biomarkers and identify AKI or progression of AKI earlier than serum creatinine (sCr). Kidney injury molecule 1 and liver-type fatty acid-binding protein (L-FABP) also show potential. NGAL and interleukin 18 may play a role in differentiating acute tubular necrosis from other forms of AKI. Combining novel biomarkers with the Model for End-Stage Liver Disease score may assist prognosis. Persistent elevations in select markers (eg, NGAL) can portend irreversible injury. Several pretransplantation markers (including sCr) predict posttransplantation kidney dysfunction. Pretransplantation assessment of clinical factors (eg, age, diabetes) and novel markers (osteopontin and tissue inhibitor of metalloproteinases 1 [TIMP-1]) may predict renal kidney recovery after LT. Intraoperative changes in biomarkers predict early post-LT AKI. Prediction of CKD remains difficult, although a combination of biomarkers (eg, beta-2 microglobulin, CD40) is promising. Novel biomarkers have yet to replace sCr in guideline-based evaluation and management of kidney dysfunction in patients with cirrhosis. We propose a theoretical framework for practical incorporation of these biomarkers that considers patient characteristics (risk for irreversible injury), markers of functional and structural change, and assessment of the AKI-CKD continuum to identify patients at the highest risk for progressive kidney disease before and after LT.

Dipeptidyl peptidase-3 is associated with severity of liver disease and circulatory complications in patients with cirrhosis

BACKGROUND

Patients with cirrhosis suffer from a complex multiorgan disturbance and their prognosis is influenced by the development of portal hypertension and systemic circulatory dysfunction. Although non-invasive techniques such as transient elastography aid in early detection, there is an unmet need for reliable markers of these clinically significant complications.

METHODS

We conducted an exploratory single-center study investigating dipeptidyl peptidase-3 (DPP3) concentrations in various vascular beds in a cohort of 48 patients with cirrhosis and 16 healthy controls. Liver vein catheterization with sampling from femoral artery and femoral, renal and hepatic veins as well as measurement of hepatic pressure and liver function via indocyanine green and galactose elimination tests were performed.

RESULTS

DPP3 concentrations were higher in cirrhotic patients compared to controls (12.6 vs. 7.4 ng/mL, p = 0.006) and increased according to the severity of cirrhosis. DPP3 associated with MELD-Na score, Child class, indocyanine green clearance, increased DPP3 with the increased hepatic venous pressure gradient (p = 0.015) as well as increased heart rate and reduced systemic vascular resistance. DPP3 concentrations predicted the presence of clinically significant portal hypertension in cirrhotic patients (AUROC 0.78, 95% CI 0.65 - 0.9).

CONCLUSION

DPP3 is a promising marker for portal hypertension and systemic hemodynamic changes in cirrhosis.

Effect of autohemotherapy in the treatment of viral infections - a systematic review

OBJECTIVE

To analyze the literature to determine whether autohemotherapy has any effect either clinically or on the immune system on viral diseases on the last ten years.

STUDY DESIGN

Systematic review.

METHODS

Searches from the year 2010, with at least 5 patients were conducted in PubMed/MEDLINE, Embase, Scopus, Cochrane, LILACS, SciELO, and Web of Science databases. Hand searches were performed in systematic reviews and literature reviews related to autohemotherapy. Unpublished manuscripts were hand-searched in specialized journals.

RESULTS

Eight articles were included. Hepatitis B virus, hepatitis C virus, and Coronavirus were evaluated. Autohemotherapy had good results in hepatitis C, hepatitis B, and Coronavirus.

CONCLUSION

Autohemotherapy is a safe practice that improves symptoms in the treatment of hepatitis B virus, hepatitis C virus, and Coronavirus. It is necessary to perform more prospective comparative studies with homogeneous protocols.

Current knowledge about biomarkers of acute kidney injury in liver cirrhosis

Acute kidney injury (AKI) is common in advanced cirrhosis. Prerenal azotemia, hepatorenal syndrome, and acute tubular necrosis are the main causes of AKI in patients with cirrhosis. Evaluation of renal function and differentiation between functional and structural kidney injury are important issues in the management of cirrhosis. However, AKI in cirrhosis exists as a complex clinical spectrum rather than concrete clinical entity. Based on current evidence, changes in serum creatinine (Cr) levels remain the most appropriate standard for defining AKI in cirrhosis. However, serum Cr has a limited role in assessing renal function in this population. This review examines previous studies that investigated the ability of recent biomarkers for AKI in cirrhosis from the perspective of earlier and accurate diagnosis, classification of AKI phenotype, and prediction of clinical outcomes. Serum cystatin C and urine neutrophil gelatinase-associated lipocalin have been extensively studied in cirrhosis, and have facilitated improved diagnosis and prognosis prediction in patients with AKI. In addition, urine N-acetyl-β-D-glucosaminidase, interleukin 18, and kidney injury molecule 1 are other promising biomarkers for advanced cirrhosis. However, the clinical significance of these markers remains unclear because there are no cut-off values defining the normal range and differentiating phenotypes of AKI. In addition, AKI has been defined in terms of serum Cr, and renal biopsy-the gold standard-has not been carried out in most studies. Further discovery of innovate biomarkers and incorporation of various markers could improve the diagnosis and prognosis prediction of AKI, and will translate into meaningful improvements in patient outcomes.

Could KIM-1 and NGAL levels predict acute kidney injury after paracentesis? - preliminary study

Background

Kidney dysfunction is a common complication in patients with severe liver cirrhosis. There is a need for discovery and validation of novel biomarkers for earlier AKI detection. The aim of this study was to determine if tubular injury markers: NGAL and KIM-1 could be helpful in the early diagnosis of AKI in patients undergoing therapeutic paracentesis.

Methods

This preliminary study included 24 adult patients diagnosed with liver cirrhosis who had been hospitalized due to massive ascites requiring paracentesis. Pre- and post-paracentesis plasma samples were taken from each patient and biomarkers were measured.

Results

Before paracentesis, the levels of serum and urinary NGAL were similar between patients and controls; while urinary KIM-1 was markedly increased in liver cirrhotic patients (0.76 vs. 0.24 ng/ml; respectively). Although urinary NGAL levels in AKI patients were 5-time greater than in non-AKI subgroup, the difference did not reach statistical significance (13.2 vs 1.5 pg/mL, p = 0.06). Serum NGAL level, post-procedure, was 3 times greater in AKI subgroup.

Conclusion

Kidney injury markers, especially serum NGAL, may be useful for the early detection of AKI. However, further research is required to determine if biomarkers of kidney injury may help identify patients with cirrhosis who would most likely benefit from early AKI prevention and treatment.

Fluid Biomarkers for Predicting the Prognosis of Liver Cirrhosis

Liver cirrhosis is the terminal stage of most chronic liver conditions, with a high risk of mortality. Careful evaluation of the prognosis of cirrhotic patients and providing precise management are crucial to reduce the risk of mortality. Although the liver biopsy and hepatic venous pressure gradient (HVPG) can efficiently evaluate the prognosis of cirrhotic patients, their application is limited due to the invasion procedures. Child-Pugh score and the model for end-stage liver disease (MELD) score had been widely used in the assessment of cirrhotic prognosis, but the defects of subjective variable application in Child-Pugh score and unsuitability to all phases of liver cirrhosis in MELD score limit their prognostic values. In recent years, continuous efforts have been made to investigate the prognostic value of body fluid biomarkers for cirrhotic patients, and promising results have been reported. Since the collection of fluid specimens is easy, noninvasive, and repeatable, fluid biomarkers can be ideal indicators to predict the prognosis of cirrhosis. Here, we reviewed noninvasive fluid biomarkers in different prognostic functions, including the prediction of survival and complication development.

Clinical utility of urinary neutrophil gelatinase-associated lipocalin and serum cystatin C in a cohort of liver cirrhosis patients with renal dysfunction: a challenge in the diagnosis of hepatorenal syndrome

OBJECTIVES

This study aimed to assess urinary neutrophil gelatinase-associated lipocalin (uNGAL) and serum cystatin C (sCys C) in liver cirrhosis patients with renal dysfunction and to evaluate their role in the diagnosis of the hepatorenal syndrome (HRS).

PATIENTS AND METHODS

Forty-five liver cirrhosis patients were enrolled in the study and they were divided into three groups; the first group included 15 patients with normal renal function, the second group included 15 patients with HRS; and the third group included 15 patients with chronic kidney disease (CKD). There was a fourth group, which included 15 healthy controls. Liver and renal function tests, as well as the estimated glomerular filtration rate were determined. uNGAL was measured using the enzyme-linked immunosorbent assay, and the uNGAL/urinary creatinine concentration (UCC) ratio was calculated. sCys C was measured using the particle-enhanced immunoturbidimetric assay.

RESULTS

The ratios of uNGAL and uNGAL/UCC were the highest among HRS patients. The combined uNGAL/UCC ratio and sCys C improved the sensitivity of diagnosis to 93.33% and specificity to 76.67%, with the highest area under the curve of 0.944, 95% confidence interval of 0.879-1.0 (P<0.001). The three biomarkers could successfully identify HRS at the following cutoffs: 84.94 ng/ml, 0.6 ng/mg, and 1.6 mg/l, respectively. Significant positive correlations were found between uNGAL, uNGAL/UCC ratios as well as sCys C and KDIGO stage in liver cirrhosis patients with CKD.

CONCLUSION

uNGAL and a better uNGAL/UCC ratio can be used alone or together with serum cystatin C as early biomarkers for HRS among patients with decompensated liver cirrhosis. Moreover, uNGAL, uNGAL/UCC as well as serum cystatin C could aid the prognostic assessment of cirrhotic patients with CKD.

Biomarkers for acute kidney injury in decompensated cirrhosis: A prospective study

AIM

Acute kidney injury (AKI) is a frequent complication in cirrhotic patients. As serum creatinine is a poor marker of renal function in this population, we aimed to study the utility of several biomarkers in this context.

METHODS

A prospective study was conducted in hospitalized patients with decompensated cirrhosis. Serum creatinine (SCr), Cystatin C (CystC), NGAL and urinary NGAL, KIM-1, protein, albumin and sodium were measured on three separate occasions. Renal resistive index (RRI) was obtained. We analyzed the value of these biomarkers to determine the presence of AKI, its aetiology [prerenal, acute tubular necrosis (ATN), or hepatorenal (HRS)], its severity and a composite clinical outcome at 30 days (death, dialysis and intensive care admission).

RESULTS

We included 105 patients, of which 55 had AKI. SCr, CystC, NGAL (plasma and urinary), urinary sodium and RRI at inclusion were independently associated with the presence of AKI. SCr, CystC and plasma NGAL were able to predict the subsequent development of AKI. Pre-renal state showed lower levels of SCr, NGAL (plasma and urinary) and RRI. ATN patients had high levels of NGAL (plasma and urinary) as well as urinary protein and sodium. HRS patients presented an intermediate pattern. All biomarkers paralleled the severity of AKI. SCr, CystC and plasma NGAL predicted the development of the composite clinical outcome with the same performance as the MELD score.

CONCLUSIONS

In patients with decompensated cirrhosis, early measurement of renal biomarkers provides valuable information on AKI aetiology. It could also improve AKI diagnosis and prognosis.

Serum NGAL Is Superior to Cystatin C in Predicting the Prognosis of Acute-on-Chronic Liver Failure

INTRODUCTION AND AIM

Acute-on-chronic liver failure (ACLF) is a syndrome with high short-term mortality, and predicting the prognosis is challenging. This study aimed to compare the performance of neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C (CysC) in predicting the 90-day mortality in patients with hepatitis B virus (HBV)-associated ACLF (HBV-ACLF).

MATERIALS AND METHODS

This prospective, observational study enrolled 54 patients with HBV-ACLF. The serum NGAL and CysC levels were determined. A multivariate logistic regression analysis was used to analyze the independent risk factors of mortality.

RESULTS

Serum NGAL, but not CysC, was found to significantly correlate with the total bilirubin, international normalized ratio, and model for end-stage liver disease (MELD). Serum NGAL [odds ratio (OR), 1.008; 95% confidence interval (CI), 1.004-1.012; P < 0.01], but not CysC, was an independent risk factor for developing hepatorenal syndrome. Moreover, NGAL (OR, 1.005; 95% CI, 1.001-1.010; P < 0.01) along with the MELD score was independently associated with the overall survival in patients with HBV-ACLF. Patients with HBV-ACLF were stratified into two groups according to the serum NGAL level at baseline (low risk: <217.11 ng/mL and high risk: ≥ 217.11 ng/mL). The 90-day mortality rate was 22.73% (5/22) in the low-risk group and 71.88% (23/32) in the high-risk group. Moreover, NGAL, but not CysC, significantly improved the MELD score in predicting the prognosis of HBV-ACLF.

CONCLUSION

The serum NGAL might be superior to CysC in predicting the prognosis of HBV-ACLF with the normal creatinine level.

Value of cystatin C, β2 macroglobulin, serum creatinine, and blood urea nitrogen in predicting hepatorenal syndrome in patients with acute-on-chronic liver failure

AIM

To assess the predictive value of cystatin C (Cys-C), β2 macroglobulin (β2-MG), serum creatinine (Scr), and blood urea nitrogen (BUN) for hepatorenal syndrome (HRS) in patients with acute-on-chronic liver failure (ACLF) .

METHODS

Thirty-six ACLF patients with HRS (HRS group) treated at our hospital from February 2014 to December 2017 were analyzed retrospectively. Thirty-six patients with ACLF without HRS were selected as an ACLF group, and 50 patients with chronic liver disease (CLD) were selected as a CLD group. Cys-C, β2-MG, Scr, and BUN were compared between the three groups. The receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic efficacy of Cys-C, β2-MG, Scr, and BUN, alone or in combination, in predicting HRS in patients with ACLF.

RESULTS

The levels of Cys-C, β2-MG, Scr, and BUN in the three groups were statistically different (F = 47.330, 23.693, 41.220, 26.715; P = 0.000 for all). Compared with the CLD and ACLF groups, Cys-C (t = 9.386, 4.807, P = 0.000 for both), β2-MG (t = 30.265, 4.116; P = 0.000 for both), Scr (t = 7.457, 7.415; P = 0.000 for both), and BUN (t = 6.608, 5.014; P = 0.000 for both) were significantly increased in the HRS group. ROC curve analysis showed that Scr had the highest AUC (0.799), followed by Cys-C (AUC = 0.789), β2-MG (AUC = 0.741), and BUN (AUC = 0.910). The combination of Cys-C, β2-MG, and Scr (AUC = 0.910) performed significantly better than any of the four indexes alone. Using the best cutoff point of the ROC curve as the predictive index, the diagnostic accuracy rate of the combination of Cys-C, β2-MG, and Scr for HRS was 80.33% (sensitivity, 91.67%; specificity, 75.58%; positive predictive value, 61.11%; negative predictive value, 95.59%). The sensitivity of combined indexes was significantly higher than any of the four indexes alone (χ² = 10, 8.692, 7.432, 3.956; P = 0.002, 0.003, 0.006, 0.047).

CONCLUSION

The levels of Cys-C, β2-MG, Scr, and BUN in ACLF patients with HRS significantly increase. The combination of Cys-C, β2-MG, and Scr has higher accuracy for predicting HRS in ACLF patients.

Bile Cast Nephropathy in Patients with Acute Kidney Injury Due to Hepatorenal Syndrome: A Postmortem Kidney Biopsy Study

Background and Aims: The role of bile cast nephropathy (BCN) in pathogenesis of hepatorenal syndrome (HRS) in decompensated cirrhosis and acute on chronic liver failure (ACLF) is unknown. This study aimed to determine the frequency of BCN detected on postmortem renal biopsy among patients with decompensated cirrhosis and ACLF who had been admitted with acute kidney injury due to HRS (HRA-AKI) and expired during that hospitalization. Methods: One-hundred-twenty-seven postmortem renal biopsies with adequate size (>1 cm in length) were included for analysis. These were obtained from 84 patients with decompensated cirrhosis and 43 patients with ACLF. Results: BCN was detected in 57 of the total 127 (44.8%) renal biopsy specimens. Patients with BCN had significantly higher levels of serum total bilirubin, total leukocyte count and model for end-stage liver disease score, as compared to those without BCN. BCN was detected in 32/43 (74.4%) of the patients with ACLF, as compared to 25/84 (29.7%) of the patients with decompensated cirrhosis (p < 0.001). On multivariate analysis, direct bilirubin (OR (95% CI): 1.27 (1121-1.698); p < 0.001) and presence of ACLF (OR (95% CI): 2.603 (1.054-7.111); p = 0.041) were found to be significant predictors of BCN on postmortem renal biopsy. Conclusion: BCN was found in 72.1% of patients with ACLF and 27.4% patients with decompensated cirrhosis who had been hospitalized with an admitting diagnosis of HRS-AKI and who expired during that hospitalization and underwent postmortem renal biopsy. Direct serum bilirubin and presence of ACLF were found to be significant predictors of BCN on postmortem renal biopsy.