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INASL-ISN Joint Position Statements on Management of Patients with Simultaneous Liver and Kidney Disease. J Clin Exp Hepatol 2021; 11:354-386. [PMID: 33994718 PMCID: PMC8103529 DOI: 10.1016/j.jceh.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/27/2020] [Indexed: 01/10/2023] Open
Abstract
Renal dysfunction is very common among patients with chronic liver disease, and concomitant liver disease can occur among patients with chronic kidney disease. The spectrum of clinical presentation and underlying etiology is wide when concomitant kidney and liver disease occur in the same patient. Management of these patients with dual onslaught is challenging and requires a team approach of hepatologists and nephrologists. No recent guidelines exist on algorithmic approach toward diagnosis and management of these challenging patients. The Indian National Association for Study of Liver (INASL) in association with Indian Society of Nephrology (ISN) endeavored to develop joint guidelines on diagnosis and management of patients who have simultaneous liver and kidney disease. For generating these guidelines, an INASL-ISN Taskforce was constituted, which had members from both the societies. The taskforce first identified contentious issues on various aspects of simultaneous liver and kidney diseases, which were allotted to individual members of the taskforce who reviewed them in detail. A round-table meeting of the Taskforce was held on 20-21 October 2018 at New Delhi to discuss, debate, and finalize the consensus statements. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications. The strength of recommendations (strong and weak) thus reflects the quality (grade) of underlying evidence (I, II, III). We present here the INASL-ISN Joint Position Statements on Management of Patients with Simultaneous Liver and Kidney Disease.
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Schacher FC, Mattos AA, Mulazzani CM, Detanico RB, Favero B, Fonseca BB, Felix PH, Pase THS, Kupski C, Machado MB, Coral GP, Wiltgen D, Mattos AZ. IMPACT OF ACUTE KIDNEY INJURY STAGING ON PROGNOSIS OF PATIENTS WITH CIRRHOSIS. ARQUIVOS DE GASTROENTEROLOGIA 2020; 57:244-248. [PMID: 32935742 DOI: 10.1590/s0004-2803.202000000-46] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 06/05/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common and severe complication of cirrhosis. OBJECTIVE To evaluate the impact of AKI staging on 30-day mortality of patients with cirrhosis. METHODS We performed a retrospective cohort study of hospitalized patients with cirrhosis. Acute kidney injury (AKI) was diagnosed according to the International Club of Ascites recommendations and staged according to the European Association for the Study of the Liver guidelines. Comparisons between groups were made by one-way analysis of variance and Tukey test. Chi-square was calculated for dichotomous variables. Comparisons of renal impairment status among patients were performed using Kaplan-Meier statistics and differences between groups were analyzed using the log-rank test. A P-value <0.05 was considered to be statistically significant. RESULTS Two hundred and thirty-two patients were included in the study. The diagnosis of AKI was performed in 98 (42.2%) of them. The overall 30-day mortality was 19.8% (46/232). Mortality increased as the degree of AKI progressed. Among patients who did not have AKI, mortality was 5.2% (7/134). When compared to patients without AKI, patients diagnosed with AKI stage 1a had mortality of 12.1% (4/33, P=0.152); patients with AKI stage 1b had mortality of 45% (18/40, P<0.001); and patients with AKI stages 2 or 3 had mortality of 68% (17/25, P<0.001). Moreover, it is noteworthy that full response to treatment was associated to a decreased mortality when compared to patients who did not show complete recovery of renal function (14.3% vs 57.9%, P<0.001). CONCLUSION AKI stages 1b or greater, but not AKI stage 1a, are associated to higher 30-day mortality of patients with cirrhosis.
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Affiliation(s)
- Fernando C Schacher
- Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brasil
| | - Angelo A Mattos
- Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brasil.,Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
| | | | - Rafaela B Detanico
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Bruna Favero
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Bárbara B Fonseca
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Patricia H Felix
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | | | - Carlos Kupski
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Marta B Machado
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Gabriela P Coral
- Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brasil.,Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
| | - Denusa Wiltgen
- Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brasil.,Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
| | - Angelo Z Mattos
- Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brasil.,Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
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AKI persistence at 48 h predicts mortality in patients with acute on chronic liver failure. Hepatol Int 2017; 11:529-539. [PMID: 28983839 DOI: 10.1007/s12072-017-9822-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 09/06/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Management of acute kidney injury (AKI) in cirrhotics has undergone a paradigm change. We evaluated the impact of AKI persistence at 48 h on outcome in patients with acute on chronic liver failure (ACLF). METHODS Consecutive patients with ACLF (n = 373) were prospectively followed. AKI was defined as increase in serum creatinine of 0.3 mg/dl or 1.5- to 2-fold from baseline. Persistent AKI was defined as nonresponsive AKI at 48 h with respect to admission serum creatinine. RESULTS AKI at admission was present in 177 (47.5 %) patients. At 48 h, 73 % patients had persistent AKI and 27 % had responsive AKI. High Model for End-Stage Liver Disease (MELD) (≥26) [p, odds ratio (OR), 95 % confidence interval (CI)] [<0.001, 3.65 (2.1-3.67)], systemic inflammatory response syndrome (SIRS) [0.03, 1.6 (1.02-21.6)], and age (≥42 years) [0.03, 1.84 (1.19-2.85)] were significant predictors of AKI persistence. Persistent AKI was associated with significantly higher in-hospital mortality [p < 0.001, hazard ratio (HR) 1.7, 95 % CI 1.32-2.27]. We further found a lower cutoff for serum creatinine of 1.14 mg/dl at 48 h with better sensitivity of 61 %, specificity of 61 %, and likelihood ratio (LR+) of 1.6, correctly classifying 61 %, as against the conventional cutoff of 1.5 mg/dl with sensitivity of 37 %, specificity of 57 %, and LR+ of 3.3, correctly classifying 56 %. This new cutoff also predicted mortality with higher odds (OR 2.4, 95 % CI 1.3-4.8) as compared with the conventional cutoff (OR 2.1, 95 % CI 1.1-4.1). CONCLUSION AKI persistence at 48 h predicts mortality better than serum creatinine of 1.5 mg/dl in patients with ACLF. Serum creatinine value of 1.14 mg/dl and smaller increases in its value should be considered for risk stratification of patients with ACLF for interventional strategies.
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Bucsics T, Krones E. Renal dysfunction in cirrhosis: acute kidney injury and the hepatorenal syndrome. Gastroenterol Rep (Oxf) 2017; 5:127-137. [PMID: 28533910 PMCID: PMC5421450 DOI: 10.1093/gastro/gox009] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 03/08/2017] [Indexed: 02/06/2023] Open
Abstract
Renal dysfunction is a common complication of liver cirrhosis and of utmost clinical and prognostic relevance. Patients with cirrhosis are more prone to developing acute kidney injury (AKI) than the non-cirrhotic population. Pre-renal AKI, the hepatorenal syndrome type of AKI (HRS-AKI, formerly known as 'type 1') and acute tubular necrosis represent the most common causes of AKI in cirrhosis. Correct differentiation is imperative, as treatment differs substantially. While pre-renal AKI usually responds well to plasma volume expansion, HRS-AKI and ATN require different specific approaches and are associated with substantial mortality. Several paradigms, such as the threshold of 2.5 mg/dL for diagnosis of HRS-AKI, have recently been abolished and novel urinary biomarkers are being investigated in order to facilitate early and correct diagnosis and treatment of HRS-AKI and other forms of AKI in patients with cirrhosis. This review summarizes the current diagnostic criteria, as well as pathophysiologic and therapeutic concepts for AKI and HRS-AKI in cirrhosis.
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Affiliation(s)
- Theresa Bucsics
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Krones
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Abstract
Renal dysfunction is prevalent in patients with advanced cirrhosis and decompensation. The presence of type 1 hepatorenal syndrome (HRS) has traditionally been defined by a set of stringent criteria based on serum creatinine levels. These diagnostic criteria have been found to be too stringent to be widely applicable to patients with cirrhosis, leading to underdiagnosis of renal failure in this population. Acute kidney injury (AKI) has now been proposed to characterize renal dysfunction in patients with cirrhosis and is defined as an increase in serum creatinine by 0.3 mg/dl in <48 h or an increase in serum creatinine by 50% from a stable baseline reading within 3 months. Type 1 HRS is renamed HRS-AKI. Stage 1 AKI is defined by 0.3 mg/dl serum creatinine or a 50% increase, stages 2 and 3 AKI are defined by a two-fold and three-fold increase in serum creatinine levels, respectively. Data collected so far suggests that even stage 1 AKI is associated with worse prognosis in patients with cirrhosis. The progression of AKI usually indicates substantially worse outcomes. A panel of biomarkers, including inflammatory markers, are envisaged to complement and enhance our current diagnostic criteria in the future and provide aetiology of the AKI.
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Affiliation(s)
- Florence Wong
- Department of Medicine, Division of Gastroenterology, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto, ON M5G2C4, Canada
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Bucsics T, Mandorfer M, Schwabl P, Bota S, Sieghart W, Ferlitsch A, Trauner M, Peck-Radosavljevic M, Reiberger T. Impact of acute kidney injury on prognosis of patients with liver cirrhosis and ascites: A retrospective cohort study. J Gastroenterol Hepatol 2015; 30:1657-65. [PMID: 25967931 DOI: 10.1111/jgh.13002] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Acute kidney injury (AKI) is a common complication in patients with liver cirrhosis, and its impact on the clinical course is increasingly recognized. Diagnostic classification systems for AKI in cirrhosis have been suggested. The prognostic significance of the respective AKI stages remains to be evaluated in decompensated cirrhosis with ascites. METHODS Data of consecutive patients with cirrhosis and ascites undergoing paracentesis at a tertiary care center were analyzed. AKI was defined as an increase in serum creatinine of ≥ 0.3 mg/dL or by ≥ 50% within 7 days after paracentesis, and classified according to (i) revised Acute Kidney Injury Network (AKIN) criteria and (ii) modified AKI criteria for cirrhosis (C-AKI). In contrast to AKIN, C-AKI stage A discriminates prognosis based on an absolute creatinine cut-off at < 1.5 mg/dL versus C-AKI stage B at ≥ 1.5 mg/dL. RESULTS The final study cohort included 239 patients. Median transplant-free survival was 768 days (95% confidence interval [CI]: 331-1205 days) without AKI, 198 (0-446) in AKI-1, 91 (0-225) in AKI-2, 19 (0-40) and in AKI-3, whereas it was 89 (20-158) days in C-AKI-A, 384 (0-1063) in C-AKI-B, and 22 (7-776) in C-AKI-C. Mild AKI was already associated with significantly increased 30-day mortality (AKI-1:26.4%, C-AKI-A:33.3%) as compared with patients without AKI (14.3%), even when serum creatinine remained within normal range (< 1.2 mg/dL) we observed a significant 30-day mortality. CONCLUSION AKIN criteria-considering small increases in serum creatinine rather than absolute thresholds-seem to be more accurate for estimating prognosis of AKI after paracentesis than C-AKI criteria. Even patients developing AKI-1 with "normal" serum creatinine are at increased risk for mortality.
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Affiliation(s)
- Theresa Bucsics
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Simona Bota
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Sieghart
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Arnulf Ferlitsch
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Markus Peck-Radosavljevic
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
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Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication of advanced cirrhosis. Type 1 hepatorenal syndrome is the best-known and most severe form of AKI, and it has a precise definition and a set of specific diagnostic criteria. More recently, it has become recognized that milder degrees of renal dysfunction also have a negative impact on patient outcome in various patient populations. Key Messages: Several definitions and criteria for staging the severity of AKI have been proposed, including the RIFLE (Risk, Injury, Failure, Loss of Function and End-Stage Renal Disease) group, the Acute Kidney Injury Network (AKIN), and the Kidney Disease: Improving Global Outcome (KDIGO) group. All of them incorporate some changes of serum creatinine and urine output in the definition and staging of AKI. The hepatology community has mostly embraced the AKIN diagnostic and staging criteria and has applied them in the prognostication of patients with advanced cirrhosis. However, the AKIN criteria have not been strictly applied in all studies on cirrhosis. This is partly related to the fact that changes in urine output are difficult to assess in advanced cirrhosis, and partly related to the difficulty in defining the baseline serum creatinine from which the change in serum creatinine is calculated. This has led to some confusion in the interpretation of results of the various studies on AKI in cirrhosis. More recently, some investigators have suggested incorporating the AKIN criteria with setting a lower limit of serum creatinine of 1.5 mg/dl in determining the diagnosis and prognosis of AKI in cirrhosis. CONCLUSIONS This is an ongoing debate as to how best to define AKI in cirrhosis. In the near future there should be prospective clinical trials that will clarify which diagnostic and staging criteria of AKI will best serve the cirrhotic population.
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Affiliation(s)
- Florence Wong
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ont., Canada
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Wong F, O'Leary JG, Reddy KR, Kamath PS, Garcia-Tsao G, Maliakkal B, Subramanian R, Thacker L, Bajaj J. A cut-off serum creatinine value of 1.5 mg/dl for AKI--to be or not to be. J Hepatol 2015; 62:741-3. [PMID: 25485798 DOI: 10.1016/j.jhep.2014.10.047] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 10/13/2014] [Accepted: 10/16/2014] [Indexed: 12/20/2022]
Affiliation(s)
- Florence Wong
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada.
| | | | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Guadalupe Garcia-Tsao
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Benedict Maliakkal
- Division of Gastroenterology, University of Rochester Medical Center, Rochester, NY, USA
| | - Ram Subramanian
- Division of Gastroenterology, Emory University Medical Center, Atlanta, GA, USA
| | - Leroy Thacker
- Biostatistics, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Jasmoham Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
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Piano S, Morando F, Angeli P. Reply to: "To close the stable door before the horse has bolted". J Hepatol 2014; 60:680-1. [PMID: 24295870 DOI: 10.1016/j.jhep.2013.11.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 11/25/2013] [Indexed: 01/24/2023]
Affiliation(s)
| | | | - Paolo Angeli
- Department of Medicine (DIMED), University of Padova, Italy.
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