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Lin B, Xiao W, Huang P, Lin X, Lin Y, Lin J, Xiao X. Association between serum magnesium concentrations and the risk of developing acute kidney injury in patients with cirrhosis: a retrospective cohort study based on the MIMIC-IV database. Ren Fail 2024; 46:2368088. [PMID: 39108151 PMCID: PMC11308976 DOI: 10.1080/0886022x.2024.2368088] [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: 03/08/2024] [Revised: 06/08/2024] [Accepted: 06/10/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND In various disease contexts, magnesium abnormalities are associated with acute kidney injury (AKI) incidence. However, this association remains unclear and has not been systematically investigated in patients with cirrhosis. Hence, we aimed to elucidate the association between admission serum magnesium levels and AKI incidence in intensive care unit (ICU)-admitted cirrhotic patients. METHODS A retrospective cohort study was conducted using MIMIC-IV2.2 data, focusing on critically ill patients with cirrhosis. We employed univariable and multivariable logistic regression and restricted cubic spline analyses to robustly address our research objectives. To further substantiate the findings, subgroup and sensitivity analyses were also conducted. RESULTS Among the 3,228 enrolled ICU-admitted cirrhotic patients, 34.4% were female, and the overall AKI incidence was 68.6% (2,213/3,228). Multivariable logistic regression analysis revealed an independent relationship between elevated serum magnesium levels and increased AKI risk (OR = 1.55 [95% CI = 1.15-2.09], p = 0.004). Compared with individuals with serum magnesium levels < 1.6 mg/dL, individuals with serum magnesium levels in Q2 (1.6-2.6 mg/dL) and Q3 (≥2.6 mg/dL) had adjusted ORs for AKI of 1.89 (95% CI = 1.34-2.65, p < 0.001) and 2.19 (95% CI = 1.27-3.75, p = 0.005), respectively. The restricted cubic spline analysis revealed that AKI risk increased linearly with increasing serum magnesium levels. Subgroup analysis revealed that the association between serum magnesium levels and AKI incidence was remarkably stable in subgroup analysis (all Pinteraction >0.05). CONCLUSIONS High serum magnesium concentrations were significantly associated with an increased AKI risk in ICU-admitted patients with cirrhosis. Further randomized trials are needed to confirm this association.
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Affiliation(s)
- Bingwen Lin
- Department of Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Wenbiao Xiao
- Department of Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Peng Huang
- Department of Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xinxin Lin
- Department of Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yuanxi Lin
- Department of Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jiandong Lin
- Department of Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xiongjian Xiao
- Department of Critical Care Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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Wang J, Niu D, Li X, Zhao Y, Ye E, Huang J, Yue S, Hou X, Wu J. Effects of 24-hour urine-output trajectories on the risk of acute kidney injury in critically ill patients with cirrhosis: a retrospective cohort analysis. Ren Fail 2024; 46:2298900. [PMID: 38178568 PMCID: PMC10773636 DOI: 10.1080/0886022x.2023.2298900] [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: 08/03/2023] [Accepted: 12/20/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is one of the most common complications for critically ill patients with cirrhosis, but it has remained unclear whether urine output fluctuations are associated with the risk of AKI in such patients. Thus, we explored the influence of 24-h urine-output trajectory on AKI in patients with cirrhosis through latent category trajectory modeling. MATERIALS AND METHODS This retrospective cohort study examined patients with cirrhosis using the MIMIC-IV database. Changes in the trajectories of urine output within 24 h after admission to the intensive care unit (ICU) were categorized using latent category trajectory modeling. The outcome examined was the occurrence of AKI during ICU hospitalization. The risk of AKI in patients with different trajectory classes was explored using the cumulative incidence function (CIF) and the Fine-Gray model with the sub-distribution hazard ratio (SHR) and the 95% confidence interval (CI) as size effects. RESULTS The study included 3,562 critically ill patients with cirrhosis, of which 2,467 (69.26%) developed AKI during ICU hospitalization. The 24-h urine-output trajectories were split into five classes (Classes 1-5). The CIF curves demonstrated that patients with continuously low urine output (Class 2), a rapid decline in urine output after initially high levels (Class 3), and urine output that decreased slowly and then stabilized at a lower level (Class 4) were at higher risk for AKI than those with consistently moderate urine output (Class 1). After fully adjusting for various confounders, Classes 2, 3, and 4 were associated with a higher risk of AKI compared with Class 1, and the respective SHRs (95% CIs) were 2.56 (1.87-3.51), 1.86 (1.34-2.59), and 1.83 1.29-2.59). CONCLUSIONS The 24-h urine-output trajectory is significantly associated with the risk of AKI in critically ill patients with cirrhosis. More attention should be paid to the dynamic nature of urine-output changes over time, which may help guide early intervention and improve patients' prognoses.
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Affiliation(s)
- Jia Wang
- Clinical Research Service Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Guangdong Engineering Research Center of Collaborative Innovation of Clinical Medical Big Data Cloud Service in Western Guangdong Medical Union, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Dongdong Niu
- Clinical Research Service Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Guangdong Engineering Research Center of Collaborative Innovation of Clinical Medical Big Data Cloud Service in Western Guangdong Medical Union, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Xiaolin Li
- Clinical Research Service Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Guangdong Engineering Research Center of Collaborative Innovation of Clinical Medical Big Data Cloud Service in Western Guangdong Medical Union, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Yumei Zhao
- Clinical Research Service Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Guangdong Engineering Research Center of Collaborative Innovation of Clinical Medical Big Data Cloud Service in Western Guangdong Medical Union, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Enlin Ye
- Clinical Research Service Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Guangdong Engineering Research Center of Collaborative Innovation of Clinical Medical Big Data Cloud Service in Western Guangdong Medical Union, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Jiasheng Huang
- Clinical Research Service Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Guangdong Engineering Research Center of Collaborative Innovation of Clinical Medical Big Data Cloud Service in Western Guangdong Medical Union, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Suru Yue
- Clinical Research Service Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Guangdong Engineering Research Center of Collaborative Innovation of Clinical Medical Big Data Cloud Service in Western Guangdong Medical Union, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Xuefei Hou
- Clinical Research Service Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Guangdong Engineering Research Center of Collaborative Innovation of Clinical Medical Big Data Cloud Service in Western Guangdong Medical Union, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Jiayuan Wu
- Clinical Research Service Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
- Guangdong Engineering Research Center of Collaborative Innovation of Clinical Medical Big Data Cloud Service in Western Guangdong Medical Union, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
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3
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Juanola A, Ma AT, Gratacós-Ginès J, Soria A, Solé C, Pose E, Ginès P. Renal Complications in Portal Hypertension. Clin Liver Dis 2024; 28:503-523. [PMID: 38945640 DOI: 10.1016/j.cld.2024.03.011] [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] [Indexed: 07/02/2024]
Abstract
Acute kidney injury (AKI) is a common complication among patients with decompensated cirrhosis and its development is associated with worse prognosis in terms of survival. Patients with decompensated cirrhosis may develop a unique type of AKI, known as hepatorenal syndrome (HRS-AKI), characterized by marked impairment of kidney function due to haemodynamic changes that occur in late stages of liver cirrhosis. Besides, patients with cirrhosis also may develop chronic alterations of kidney function (chronic kidney disease, CKD), the incidence of which is increasing markedly and may be associated with clinical complications. The aim of this review is to provide the reader with an update of the most relevant aspects of alterations of kidney function in patients with cirrhossi that may be useful for theri clinical practice.
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Affiliation(s)
- Adrià Juanola
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Ann Thu Ma
- Toronto Centre for Liver Disease Francis Family Liver Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jordi Gratacós-Ginès
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Anna Soria
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Cristina Solé
- Department of Gastroenterology and Hepatology, Consorci Corporació Sanitària Parc Taulí, Sabadell, Spain
| | - Elisa Pose
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; School of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain.
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Lekakis V, Gkoufa A, Vlachogiannakos J, Papatheodoridis GV, Cholongitas E. Incidence and risk factors of acute kidney injury in cirrhosis: a systematic review and meta-analysis of 5,202,232 outpatients, inpatients, and ICU-admitted patients. Expert Rev Gastroenterol Hepatol 2024:1-12. [PMID: 39001566 DOI: 10.1080/17474124.2024.2380299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 07/11/2024] [Indexed: 07/18/2024]
Abstract
INTRODUCTION Acute kidney injury (AKI) is a commonly seen condition in the natural course of cirrhosis. The aim of this study was to evaluate the pooled incidence and risk factors of AKI in different clinical stages and situations in patients with cirrhosis. METHODS Search was conducted on 13 December 2023 across MEDLINE (PubMed), Embase, and Cochrane databases. Meta-analysis was performed using a generalized linear mixed model. RESULTS In total, 73 studies with 5,202,232 patients were finally enrolled in the meta-analysis. AKI commonly occurs among hospitalized cirrhotics experiencing any decompensation event (29%) as well as among stable outpatients (28%) throughout a 1-year follow-up period. On admission, patients with infection or sepsis/septic shock had the highest AKI rate (47%), followed by those with hepatic encephalopathy (41%). Furthermore, the severity of liver disease proved to be a substantial driver for AKI development, while patients at intensive care unit had the greatest AKI incidence (61%). CONCLUSIONS Both hospitalized patients and stable outpatients with cirrhosis exhibited an elevated susceptibility to AKI. Patients at intensive care unit and those with severe liver disease, infection, sepsis/septic shock, hepatic encephalopathy, or acute on chronic liver failure upon admission are at higher risk for AKI. TRIAL REGISTRATION PROSPERO, registered 09/12/23, CRD42023487736.
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Affiliation(s)
- Vasileios Lekakis
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece
| | - Aikaterini Gkoufa
- First Department of Internal Medicine, "Laiko", General Hospital, Medical School of National and Kapodistrian University of Athens, Athens, Greece
| | - John Vlachogiannakos
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece
| | - George V Papatheodoridis
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece
| | - Evangelos Cholongitas
- First Department of Internal Medicine, "Laiko", General Hospital, Medical School of National and Kapodistrian University of Athens, Athens, Greece
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Nadim MK, Kellum JA, Forni L, Francoz C, Asrani SK, Ostermann M, Allegretti AS, Neyra JA, Olson JC, Piano S, VanWagner LB, Verna EC, Akcan-Arikan A, Angeli P, Belcher JM, Biggins SW, Deep A, Garcia-Tsao G, Genyk YS, Gines P, Kamath PS, Kane-Gill SL, Kaushik M, Lumlertgul N, Macedo E, Maiwall R, Marciano S, Pichler RH, Ronco C, Tandon P, Velez JCQ, Mehta RL, Durand F. Acute kidney injury in patients with cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) joint multidisciplinary consensus meeting. J Hepatol 2024; 81:163-183. [PMID: 38527522 PMCID: PMC11193657 DOI: 10.1016/j.jhep.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 03/27/2024]
Abstract
Patients with cirrhosis are prone to developing acute kidney injury (AKI), a complication associated with a markedly increased in-hospital morbidity and mortality, along with a risk of progression to chronic kidney disease. Whereas patients with cirrhosis are at increased risk of developing any phenotype of AKI, hepatorenal syndrome (HRS), a specific form of AKI (HRS-AKI) in patients with advanced cirrhosis and ascites, carries an especially high mortality risk. Early recognition of HRS-AKI is crucial since administration of splanchnic vasoconstrictors may reverse the AKI and serve as a bridge to liver transplantation, the only curative option. In 2023, a joint meeting of the International Club of Ascites (ICA) and the Acute Disease Quality Initiative (ADQI) was convened to develop new diagnostic criteria for HRS-AKI, to provide graded recommendations for the work-up, management and post-discharge follow-up of patients with cirrhosis and AKI, and to highlight priorities for further research.
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Affiliation(s)
- Mitra K Nadim
- Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lui Forni
- School of Medicine, University of Surrey and Critical Care Unit, Royal Surrey Hospital Guildford UK
| | - Claire Francoz
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, Paris, France
| | | | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, Department of Critical Care, London, UK
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jody C Olson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED, University and Hospital of Padova, Padova, Italy
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Elizabeth C Verna
- Division of Digestive and Liver Diseases, Columbia University, New York, NY, USA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Divisions of Critical Care Medicine and Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, University and Teaching Hospital of Padua, Italy
| | - Justin M Belcher
- Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Scott W Biggins
- Division of Gastroenterology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Akash Deep
- Pediatric Intensive Care Unit, King's College Hospital, London, UK
| | - Guadalupe Garcia-Tsao
- Digestive Diseases Section, Yale University School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Yuri S Genyk
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Division of Abdominal Organ Transplantation at Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Pere Gines
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi-Sunyer and Ciber de Enfermedades Hepàticas y Digestivas, Barcelona, Catalonia, Spain
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Nuttha Lumlertgul
- Excellence Centre in Critical Care Nephrology and Division of Nephrology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Etienne Macedo
- Division of Nephrology, Department of Medicine, University of California San Diego, CA, USA
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Raimund H Pichler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza-Italy
| | - Puneeta Tandon
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Juan-Carlos Q Velez
- Department of Nephrology, Ochsner Health, New Orleans, LA, USA; Ochsner Clinical School, The University of Queensland, Brisbane, QLD, Australia
| | - Ravindra L Mehta
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - François Durand
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, Paris, France; University Paris Cité, Paris, France.
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Parvataneni S, Sarkis Y, Haugh M, Baker B, Tang Q, Nephew LD, Ghabril MS, Chalasani NP, Vuppalanchi R, Orman ES, Harrison NE, Desai AP. A Comprehensive Evaluation of Emergency Department Utilization by Patients With Cirrhosis. Am J Gastroenterol 2024:00000434-990000000-01201. [PMID: 38912688 DOI: 10.14309/ajg.0000000000002905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 06/06/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION Emergency department (ED)-based care is required for cirrhosis management, yet the burden of cirrhosis-related ED healthcare utilization is understudied. We aimed to describe ED utilization within a statewide health system and compare the outcomes of high ED use (HEDU) vs non-HEDU in individuals with cirrhosis. METHODS We retrospectively reviewed charts of adults with cirrhosis who presented to any of 16 EDs within the Indiana University Health system in 2021. Patient characteristics, features of the initial ED visit, subsequent 90-day healthcare use, and 360-day outcomes were collected. Multivariable logistic regression models were used to identify predictors HEDU status which was defined as ≥2 ED visits within 90 days after the index ED visit. RESULTS There were 2,124 eligible patients (mean age 61.3 years, 53% male, and 91% White). Major etiologies of cirrhosis were alcohol (38%), metabolic dysfunction-associated steatohepatitis (27%), and viral hepatitis (21%). Cirrhosis was newly diagnosed in the ED visit for 18.4%. Most common reasons for ED visits were abdominal pain (21%), shortness of breath (19%), and ascites/volume overload (16%). Of the initial ED visits, 20% (n = 424) were potentially avoidable. The overall 90-day mortality was 16%. Within 90 days, there were 366 HEDU (20%). Notable variables independently associated with HEDU were model for end-stage liver disease-sodium (adjusted odds ratio [aOR] 1.044, 95% confidence interval [CI] 1.005-1.085), prior ED encounter (aOR 1.520, 95% CI 1.136-2.034), and avoidable initial ED visit (aOR 1.938, 95% CI 1.014-3.703). DISCUSSION Abdominal pain, shortness of breath, and ascites/fluid overload are the common presenting reasons for ED visits for patients with cirrhosis. Patients with cirrhosis presenting to the ED experience a 90-day mortality rate of 16%, and among those who initially visited the ED, 20% were HEDU. We identified several variables independently associated with HEDU. Our observations pave the way for developing interventions to optimize the care of patients with cirrhosis presenting to the ED and to lower repeated ED visits.
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Affiliation(s)
- Swetha Parvataneni
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Yara Sarkis
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Michelle Haugh
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Brittany Baker
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Qing Tang
- Department of Biostatistics, Indiana University, Indianapolis, Indiana, USA
| | - Lauren D Nephew
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Naga P Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Raj Vuppalanchi
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | | | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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7
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Aguirre-Villarreal D, Leal-Villarreal MADJ, García-Juárez I, Argaiz ER, Koratala A. Sound waves and solutions: Point-of-care ultrasonography for acute kidney injury in cirrhosis. World J Crit Care Med 2024; 13:91212. [PMID: 38855265 PMCID: PMC11155499 DOI: 10.5492/wjccm.v13.i2.91212] [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: 12/24/2023] [Revised: 03/05/2024] [Accepted: 04/22/2024] [Indexed: 06/03/2024] Open
Abstract
This article delves into the intricate challenges of acute kidney injury (AKI) in cirrhosis, a condition fraught with high morbidity and mortality. The complexities arise from distinguishing between various causes of AKI, particularly hemodynamic AKI, in cirrhotic patients, who experience hemodynamic changes due to portal hypertension. The term "hepatocardiorenal syndrome" is introduced to encapsulate the intricate interplay among the liver, heart, and kidneys. The narrative emphasizes the often-overlooked aspect of cardiac function in AKI assessments in cirrhosis, unveiling the prevalence of cirrhotic cardiomyopathy marked by impaired diastolic function. The conventional empiric approach involving volume expansion and vasopressors for hepatorenal syndrome is critically analyzed, highlighting potential risks and variable patient responses. We advocate for a nuanced algorithm for AKI evaluation in cirrhosis, prominently featuring point-of-care ultrasonography (POCUS). POCUS applications encompass assessing fluid tolerance, detecting venous congestion, and evaluating cardiac function.
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Affiliation(s)
- David Aguirre-Villarreal
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | | | - Ignacio García-Juárez
- Unidad de Hepatología y Trasplante, Departamento de Gastroenterología, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City 14080, Mexico
| | - Eduardo R Argaiz
- Departamento de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City 64710, Mexico
| | - Abhilash Koratala
- Department of Nephrology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
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8
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Gonzalez SA, Asrani SK. Priority for kidney after liver transplantation: A safety net for all? Liver Transpl 2024; 30:563-564. [PMID: 38421950 DOI: 10.1097/lvt.0000000000000354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Stevan A Gonzalez
- Division of Hepatology, Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White All Saints Medical Center Fort Worth, Fort Worth, Texas, USA
- Department of Medicine, Burnett School of Medicine at TCU, Fort Worth, Texas, USA
| | - Sumeet K Asrani
- Division of Hepatology, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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9
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Banegas-Deras EJ, Mazón-Ruiz J, Romero-González G, Ruiz-Cobo JC, Sanz-García C, Serrano-Soto M, Sánchez E, Argaiz ER. Acute kidney injury and point-of-care ultrasound in liver cirrhosis: redefining hepatorenal syndrome. Clin Kidney J 2024; 17:sfae112. [PMID: 38726210 PMCID: PMC11079671 DOI: 10.1093/ckj/sfae112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Indexed: 05/12/2024] Open
Abstract
Acute kidney injury (AKI) in patients with cirrhosis is a diagnostic challenge due to multiple and sometimes overlapping possible etiologies. Many times, diagnosis cannot be made based on case history, physical examination or laboratory data, especially when the nephrologist is faced with AKI with a hemodynamic basis, such as hepatorenal syndrome. In addition, the guidelines still include generalized recommendations regarding withdrawal of diuretics and plasma volume expansion with albumin for 48 h, which may be ineffective and counterproductive and may have iatrogenic effects, such as fluid overload and acute cardiogenic pulmonary edema. For this reason, the use of new tools, such as hemodynamic point-of-care ultrasound (PoCUS), allows us to phenotype volume status more accurately and ultimately guide medical treatment in a noninvasive, rapid and individualized manner.
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Affiliation(s)
| | - Jaime Mazón-Ruiz
- Nephrology Department, Central University Hospital of Asturias, Oviedo, Spain
| | - Gregorio Romero-González
- Nephrology Department, Germans Trias i Pujol University Hospital, Badalona, Spain
- International Renal Research Institute of Vicenza, Vicenza, Italy
| | - Juan Carlos Ruiz-Cobo
- Liver Unit, Vall d'Hebron University Hospital, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Clara Sanz-García
- Nephrology Department, Grande Covián de Arriondas Hospital, Arriondas, Spain
| | - Mara Serrano-Soto
- International Renal Research Institute of Vicenza, Vicenza, Italy
- Nephrology Department, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Emilio Sánchez
- Nephrology Department, Cabueñes University Hospital, Gijón, Spain
| | - Eduardo R Argaiz
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City, Mexico
- Departamento de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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10
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Belmonte R, Silva-Rodriguez M, Barbé F, Bensenane M, Haghenejad V, Vrillon I, Alla A, Flahault A, Kormann R, Corbel A, Aitdjafer Z, Quilliot D, Derain-Dubourg L, Namour F, Guéant JL, Bronowicki JP, Oussalah A. Multiparametric renal function assessment in cirrhotic patients shows high prevalence of medically actionable changes in multiple modules. Hepatol Res 2024. [PMID: 38662338 DOI: 10.1111/hepr.14050] [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: 01/31/2024] [Revised: 03/24/2024] [Accepted: 04/03/2024] [Indexed: 04/26/2024]
Abstract
AIM Renal dysfunction is a common complication of cirrhosis, occurring either as part of multiorgan involvement in acute illness or secondary to advanced liver disease. To date, no study has comprehensively assessed multiple renal function parameters in hospitalized patients with cirrhosis through a multiparametric analysis of renal biochemistry markers. METHODS We conducted a retrospective, observational study including all consecutive patients hospitalized with cirrhosis who underwent a 43-multiparametric renal function assessment between January 1, 2021, and June 30, 2023. RESULTS All patients showed at least one of the following renal abnormalities: Kidney Disease: Improving Global Outcomes stage G2 or higher, sodium and/or chloride excretion fraction <1%, electrolyte-free water clearance <0.4 mL/min, or tubular maximum phosphate reabsorption capacity <0.8 mmol/L. The estimated glomerular filtration rate equations significantly overestimated the measured creatinine clearance with median differences of +14 mL/min/1.73 m2 (95% CI 6-29) and +9 mL/min/1.73 m2 (95% CI 2-15) for European Kidney Function Consortium equations, respectively. Notably, 54% and 39% of patients demonstrated estimated glomerular filtration rates exceeding 30% of the measured creatinine clearance when the Chronic Kidney Disease - Epidemiology Collaboration and European Kidney Function Consortium formulas were employed, respectively. Substantial discrepancies in Kidney Disease: Improving Global Outcomes stage assignments were observed between the estimated glomerular filtration rate- and measured creatinine clearance-based assessments. CONCLUSIONS This study underscores the value of a multiparametric renal function assessment as a routine tool for evaluating renal function in patients with cirrhosis. A high prevalence of medically actionable renal abnormalities spanning multiple renal function modules, including alterations in glomerular function, salt and solute-free water excretion, and proximal tubule phosphate reabsorption, has been demonstrated in hospitalized patients with cirrhosis.
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Affiliation(s)
- Richard Belmonte
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, and Nutrition, University Hospital of Nancy, Nancy, France
- Reference Medical Biology Laboratory for Biochemical and Molecular Explorations of Uro-nephrological Diseases, University Hospital of Nancy, Nancy, France
| | - Maël Silva-Rodriguez
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, and Nutrition, University Hospital of Nancy, Nancy, France
- Reference Medical Biology Laboratory for Biochemical and Molecular Explorations of Uro-nephrological Diseases, University Hospital of Nancy, Nancy, France
| | - Françoise Barbé
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, and Nutrition, University Hospital of Nancy, Nancy, France
- Reference Medical Biology Laboratory for Biochemical and Molecular Explorations of Uro-nephrological Diseases, University Hospital of Nancy, Nancy, France
| | - Mouni Bensenane
- Department of Gastroenterology and Liver Diseases, University Hospital of Nancy, Nancy, France
| | - Vincent Haghenejad
- Department of Gastroenterology and Liver Diseases, University Hospital of Nancy, Nancy, France
- University of Lorraine, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, Nancy, France
| | - Isabelle Vrillon
- Pediatric Nephrology Unit, University Hospital of Nancy, Nancy, France
| | - Asma Alla
- Department of Nephrology, University Hospital of Nancy, Nancy, France
| | - Adrien Flahault
- Department of Nephrology, University Hospital of Nancy, Nancy, France
| | - Raphael Kormann
- Department of Nephrology, University Hospital of Nancy, Nancy, France
| | - Alice Corbel
- Department of Nephrology, University Hospital of Nancy, Nancy, France
| | - Zakia Aitdjafer
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, and Nutrition, University Hospital of Nancy, Nancy, France
- Reference Medical Biology Laboratory for Biochemical and Molecular Explorations of Uro-nephrological Diseases, University Hospital of Nancy, Nancy, France
| | - Didier Quilliot
- University of Lorraine, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, Nancy, France
- Department of Endocrinology Diabetology and Nutrition, University Hospital of Nancy, Nancy, France
| | - Laurence Derain-Dubourg
- Nephrology, Dialysis, Hypertension and Functional Renal Exploration, Edouard Herriot Hospital, Hospices Civils de Lyon and Université Lyon 1, Lyon, France
| | - Farès Namour
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, and Nutrition, University Hospital of Nancy, Nancy, France
- Reference Medical Biology Laboratory for Biochemical and Molecular Explorations of Uro-nephrological Diseases, University Hospital of Nancy, Nancy, France
- University of Lorraine, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, Nancy, France
- Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, Nancy, France
| | - Jean-Louis Guéant
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, and Nutrition, University Hospital of Nancy, Nancy, France
- Reference Medical Biology Laboratory for Biochemical and Molecular Explorations of Uro-nephrological Diseases, University Hospital of Nancy, Nancy, France
- University of Lorraine, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, Nancy, France
- Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, Nancy, France
| | - Jean-Pierre Bronowicki
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, and Nutrition, University Hospital of Nancy, Nancy, France
- Department of Gastroenterology and Liver Diseases, University Hospital of Nancy, Nancy, France
- University of Lorraine, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, Nancy, France
| | - Abderrahim Oussalah
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, and Nutrition, University Hospital of Nancy, Nancy, France
- Reference Medical Biology Laboratory for Biochemical and Molecular Explorations of Uro-nephrological Diseases, University Hospital of Nancy, Nancy, France
- University of Lorraine, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, Nancy, France
- Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, Nancy, France
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11
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Pose E, Piano S, Juanola A, Ginès P. Hepatorenal Syndrome in Cirrhosis. Gastroenterology 2024; 166:588-604.e1. [PMID: 38246506 DOI: 10.1053/j.gastro.2023.11.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/10/2023] [Accepted: 11/19/2023] [Indexed: 01/23/2024]
Abstract
Hepatorenal syndrome (HRS) is a form of kidney dysfunction that characteristically occurs in liver cirrhosis. It is characterized by a marked impairment of kidney function in response to circulatory and hemodynamic alterations that occur in advanced stages of liver cirrhosis, aggravated by systemic inflammation and bacterial translocation. The classical definitions of the types of HRS have been recently revisited and 2 forms of HRS have been redefined: the acute form, referred to as acute kidney injury (HRS-AKI), and the chronic form, referred to as chronic kidney disease. HRS-AKI is one of the most severe forms of AKI in patients with cirrhosis and it consists of an abrupt impairment of kidney function, frequently triggered by an infection, appearing in the setting of advanced decompensated cirrhosis. Differential diagnosis with other causes of AKI is crucial because HRS-AKI requires a specific treatment. Differential diagnosis with AKI-acute tubular necrosis may be challenging and kidney biomarkers may be useful in this setting. Treatment of HRS-AKI is based on the administration of vasoconstrictor drugs in combination with volume expansion with albumin. Prognosis of HRS-AKI is poor, and the ideal definitive treatment consists of liver transplantation or simultaneous liver-kidney transplantation. HRS-AKI has a big impact on patients' quality of life. Management of HRS-AKI remains challenging in specific situations such as alcohol-associated hepatitis or metabolic-associated steatotic liver disease cirrhosis. Developing preventive measures for HRS-AKI, improving its early identification, discovering new biomarkers for differential diagnosis, and improving the response to therapy are some of the unmet needs in the field of HRS-AKI.
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Affiliation(s)
- Elisa Pose
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Adrià Juanola
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clínic of Barcelona, Barcelona, Catalunya, Spain; School of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
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12
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Ma AT, Solé C, Juanola A, Escudé L, Napoleone L, Avitabile E, Pérez-Guasch M, Carol M, Pompili E, Gratacós-Ginés J, Soria A, Rubio AB, Cervera M, Moreta MJ, Morales-Ruiz M, Solà E, Poch E, Fabrellas N, Graupera I, Pose E, Ginès P. Prospective validation of the EASL management algorithm for acute kidney injury in cirrhosis. J Hepatol 2024:S0168-8278(24)00157-0. [PMID: 38479614 DOI: 10.1016/j.jhep.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 02/27/2024] [Accepted: 03/08/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND & AIMS The management of acute kidney injury (AKI) in cirrhosis is challenging. The EASL guidelines proposed an algorithm for the management of AKI, but this has never been validated. We aimed to prospectively evaluate this algorithm in clinical practice. METHODS We performed a prospective cohort study in consecutive hospitalized patients with cirrhosis and AKI. The EASL management algorithm includes identification/treatment of precipitating factors, 2-day albumin infusion in patients with AKI ≥stage 1B, and treatment with terlipressin in patients with hepatorenal syndrome (HRS-AKI). The primary outcome was treatment response, which included both full and partial response. Secondary outcomes were survival and adverse events associated with terlipressin therapy. RESULTS A total of 202 AKI episodes in 139 patients were included. Overall treatment response was 80%, while renal replacement therapy was required in only 8%. Response to albumin infusion was achieved in one-third of episodes. Of patients not responding to albumin, most (74%) did not meet the diagnostic criteria of HRS-AKI, with acute tubular necrosis (ATN) being the most common phenotype. The response rate in patients not meeting the criteria for HRS-AKI was 70%. Only 30 patients met the diagnostic criteria for HRS-AKI, and their response rate to terlipressin was 61%. Median time from AKI diagnosis to terlipressin initiation was only 2.5 days. While uNGAL (urinary neutrophil gelatinase-associated lipocalin) could differentiate ATN from other phenotypes (AUROC 0.78), it did not predict response to therapy in HRS-AKI. Ninety-day transplant-free survival was negatively associated with MELD-Na, ATN and HRS-AKI as well as uNGAL. Three patients treated with terlipressin developed pulmonary edema. CONCLUSIONS The application of the EASL AKI algorithm is associated with very good response rates and does not significantly delay initiation of terlipressin therapy. IMPACT AND IMPLICATIONS The occurrence of acute kidney injury (AKI) in patients with cirrhosis is associated with poor short-term mortality. Improving its rapid identification and prompt management was the focus of the recently proposed EASL AKI algorithm. This is the first prospective study demonstrating that high AKI response rates are achieved with the use of this algorithm, which includes identification of AKI, treatment of precipitating factors, a 2-day albumin challenge in patients with AKI ≥1B, and supportive therapy in patients with persistent AKI not meeting HRS-AKI criteria or terlipressin with albumin in those with HRS-AKI. These findings support the use of this algorithm in clinical practice.
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Affiliation(s)
- Ann Thu Ma
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain; Toronto Centre for Liver Disease, University Health Network, Toronto, Canada
| | - Cristina Solé
- Hepatology Unit, Digestive Service, Parc Taulí University Hospital, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Adrià Juanola
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain
| | - Laia Escudé
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain
| | - Laura Napoleone
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain
| | - Emma Avitabile
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain
| | - Martina Pérez-Guasch
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Marta Carol
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Enrico Pompili
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain
| | - Jordi Gratacós-Ginés
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain
| | - Anna Soria
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain
| | - Ana Belén Rubio
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Marta Cervera
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Maria José Moreta
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain
| | - Manuel Morales-Ruiz
- Faculty of Medicine and Health Sciences, University of Barcelona, Spain; Biochemistry and Molecular Genetics department, Hospital Clinic, Barcelona, Spain
| | - Elsa Solà
- Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford, California, USA
| | - Esteban Poch
- Faculty of Medicine and Health Sciences, University of Barcelona, Spain; Nephrology and Kidney Transplant department, Hospital Clinic, Barcelona, Spain
| | - Núria Fabrellas
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Isabel Graupera
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Elisa Pose
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Spain.
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13
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Patidar KR, Cullaro G, Naved MA, Kabir S, Grama A, Orman ES, Piano S, Allegretti AS. Prognostic significance of acute kidney injury stage 1B in hospitalized patients with cirrhosis: A US nationwide study. Liver Transpl 2024; 30:244-253. [PMID: 37556190 PMCID: PMC10853477 DOI: 10.1097/lvt.0000000000000241] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/31/2023] [Indexed: 08/10/2023]
Abstract
Understanding the prognostic significance of acute kidney injury (AKI) stage 1B [serum creatinine (sCr) ≥1.5 mg/dL] compared with stage 1A (sCr < 1.5 mg/dL) in a US population is important as it can impact initial management decisions for AKI in hospitalized cirrhosis patients. Therefore, we aimed to define outcomes associated with stage 1B in a nationwide US cohort of hospitalized cirrhosis patients with AKI. Hospitalized cirrhosis patients with AKI in the Cerner-Health-Facts database from January 2009 to September 2017 (n = 6250) were assessed for AKI stage 1 (≥1.5-2-fold increase in sCr from baseline) and were followed for 90 days for outcomes. The primary outcome was 90-day mortality; secondary outcomes were in-hospital AKI progression and AKI recovery. Competing-risk multivariable analysis was performed to determine the independent association between stage 1B, 90-day mortality (liver transplant as a competing risk), and AKI recovery (death/liver transplant as a competing risk). Multivariable logistic regression analysis was performed to determine the independent association between stage 1B and AKI progression. In all, 4654 patients with stage 1 were analyzed: 1A (44.3%) and 1B (55.7%). Stage 1B patients had a significantly higher cumulative incidence of 90-day mortality compared with stage 1A patients, 27.2% versus 19.7% ( p < 0.001). In multivariable competing-risk analysis, patients with stage 1B (vs. 1A) had a higher risk for mortality at 90 days [sHR 1.52 (95% CI 1.20-1.92), p = 0.001] and decreased probability for AKI recovery [sHR 0.76 (95% CI 0.69-0.83), p < 0.001]. Furthermore, in multivariable logistic regression analysis, AKI stage 1B (vs. 1A) was independently associated with AKI progression, OR 1.42 (95% CI 1.14-1.72) ( p < 0.001). AKI stage 1B patients have a significantly higher risk for 90-day mortality, AKI progression, and reduced probability of AKI recovery compared with AKI stage 1A patients. These results could guide initial management decisions for AKI in hospitalized patients with cirrhosis.
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Affiliation(s)
- Kavish R. Patidar
- Department of Medicine, Section of Gastroenterology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Giuseppe Cullaro
- Department of Medicine, Division of Gastroenterology, University of California-San Francisco, San Francisco, California, USA
| | - Mobasshir A. Naved
- Department of Computer Science, Purdue University, West Lafayette, Indiana, USA
| | - Shaowli Kabir
- College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Ananth Grama
- Department of Computer Science, Purdue University, West Lafayette, Indiana, USA
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Salvatore Piano
- Department of Medicine, Unit of Internal Medicine and Hepatology, University of Padova, Padova, Italy
| | - Andrew S. Allegretti
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
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14
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Song X, Romeiro FG, Wang J, Yin Y, Philips CA, Yang X, Liu X, Wu W, Bernardinelli MVT, Santos de Souza R, Theruvath AH, Lin S, Qi X. Development and validation of modified Liaoning score for predicting the prognosis of liver cirrhosis: a retrospective, international multicenter, observational study. Expert Rev Gastroenterol Hepatol 2024; 18:121-128. [PMID: 38362663 DOI: 10.1080/17474124.2024.2320238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/14/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Liaoning score has been developed and validated to predict the risk of esophageal varices in liver cirrhosis. This study aimed to further modify the Liaoning score by combining clinical and laboratory parameters to predict the long-term outcome of cirrhotic patients. METHODS First, 474 cirrhotic patients were retrospectively enrolled from Shenyang, China as the training cohort. Independent predictors for death were identified by competing risk analyses, and then a new prognostic model, called as modified Liaoning score, was developed. Its performance was externally validated at three centers from Fuzhou, China (n = 1944), Jinan, China (n = 485), and São Paulo, Brazil (n = 221). RESULTS Age, total bilirubin (TBIL), albumin (ALB), serum creatinine (SCr), and Liaoning score were independently associated with death in the training cohort. Modified Liaoning score = 0.159×Liaoning score + 0.010×TBIL(µmol/L)+0.029×age(years)+0.011×SCr(µmol/L)-0.037×ALB(g/L). The area under curve of modified Liaoning score was 0.714 (95%CI = 0.655-0.773), which was higher than that of Child-Pugh score (0.707, 95%CI = 0.645-0.770), MELD score (0.687, 95%CI = 0.623-0.751), and Liaoning score (0.583, 95%CI = 0.513-0.654). A modified Liaoning score of ≥ 1.296 suggested a higher cumulative incidence of death in liver cirrhosis (p < 0.001). Modified Liaoning score still had the highest prognostic performance in Chinese and Brazilian validation cohorts. CONCLUSIONS Modified Liaoning score can be considered for predicting the long-term outcome of cirrhotic patients.
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Affiliation(s)
- Xiaoting Song
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Teaching Hospital of Dalian Medical University), Shenyang, China
| | - Fernando Gomes Romeiro
- Department of Internal Medicine, Botucatu Medical School, Universidade Estadual Paulista (UNESP), São Paulo, Brazil
| | - Jing Wang
- Department of Gastroenterology, The 960th Hospital of the PLA, Jinan, China
| | - Yue Yin
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Teaching Hospital of Dalian Medical University), Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Cyriac Abby Philips
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Xinyi Yang
- Liver Research Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xiaofeng Liu
- Department of Gastroenterology, The 960th Hospital of the PLA, Jinan, China
| | - Wenming Wu
- Department of Gastroenterology, The 960th Hospital of the PLA, Jinan, China
| | | | - Roger Santos de Souza
- Department of Internal Medicine, Botucatu Medical School, Universidade Estadual Paulista (UNESP), São Paulo, Brazil
| | - Arif Hussain Theruvath
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Su Lin
- Liver Research Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Teaching Hospital of Dalian Medical University), Shenyang, China
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15
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Gaurnizo-Ortiz M, Nephew LD, Vilar-Gomez E, Kettler CD, Slaven JE, Ghabril MS, Desai AP, Orman ES, Chalasani N, Gawrieh S, Patidar KR. Clinical characteristics and prognosis of hospitalized patients with moderate alcohol-associated hepatitis. Liver Int 2024; 44:241-249. [PMID: 37904305 DOI: 10.1111/liv.15771] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/14/2023] [Accepted: 10/15/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND AND AIMS Little is known about the clinical characteristics and prognosis of hospitalized patients with moderate alcohol-associated hepatitis (mAH) as compared to severe alcohol-associated hepatitis (sAH). Therefore, we aimed to describe the clinical characteristics and risk factors associated with mortality in hospitalized mAH patients. METHODS Patients hospitalized with alcohol-associated hepatitis (AH) from 1 January 2010 to 31 December 2020 at a large US healthcare system [11 hospitals, one liver transplant centre] were retrospectively analysed for outcomes. Primary outcome was 90-day mortality. AH and mAH were defined according to NIAAA Alcoholic Hepatitis Consortia and Model for End-stage Liver Disease Score ≤ 20 respectively. Multivariable Cox regression analysis was performed to identify independent risk factors associated with 90-day mortality. RESULTS 1504 AH patients were hospitalized during the study period, of whom 39% (n = 590) had mAH. Compared to sAH patients, mAH patients were older (50 vs. 48 years, p < 0.001) and less likely to have underlying cirrhosis (74% vs. 83%, p < 0.001). There were no differences between the two groups for median alcohol intake g/day (mAH 140.0 vs. sAH 112.0, p = 0.071). The cumulative proportion surviving at 90 days was 88% in mAH versus 62% in sAH (p < 0.001). On multivariable analysis, older age [HR 1.03 (95% CI 1.00-1.06), p = 0.020], corticosteroid use [HR 1.80 (95% CI 1.06-3.06), p = 0.030] and acute kidney injury (AKI) [HR 2.43 (95% CI 1.33-4.47), p = 0.004] were independently associated with 90-day mortality. CONCLUSIONS mAH carries a 12% mortality rate at 90 days. Age, AKI and corticosteroid use were associated with an increased risk for 90-day mortality. Avoidance of corticosteroids and strategies to reduce the risk of AKI could improve outcomes in mAH patients.
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Affiliation(s)
- Maria Gaurnizo-Ortiz
- Division of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lauren D Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eduardo Vilar-Gomez
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Carla D Kettler
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - James E Slaven
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Samer Gawrieh
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kavish R Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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Desai AP, Parvataneni S, Knapp SM, Nephew LD, Chalasani N, Ghabril MS, Orman ES. Hospital frailty risk score is superior to legacy comorbidity indices for risk adjustment of in-hospital cirrhosis cases. JHEP Rep 2024; 6:100955. [PMID: 38192536 PMCID: PMC10772247 DOI: 10.1016/j.jhepr.2023.100955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/17/2023] [Indexed: 01/10/2024] Open
Abstract
Background & Aims The hospital frailty risk score (HFRS) identifies older patients at risk of poor outcomes and may have value in cirrhosis. We compared the Charlson (CCI), Elixhauser (ECI), and cirrhosis (CirCom) comorbidity indices with the HFRS in predicting outcomes for cirrhosis hospitalisations. Methods Using the National Inpatient Sample (quarter 4 of 2015-2019), we analysed cirrhosis hospitalisations. For each index, we described the prevalence of comorbid conditions and inpatient mortality. We compared the ability of CCI, ECI, CirCom, and HFRS to predict inpatient mortality. Raw and adjusted models predicting inpatient mortality were compared using the area under the receiver operating characteristic curve and the Akaike information criterion. Results The cohort's (N = 626,553) median age was 61 years (IQR 52-68 years), 60% were male, cirrhosis was caused by alcohol in 43%, and 38% had ascites. The median comorbidity scores are as follows: ECI 4 (IQR 3-6), CCI 5 (IQR 4-8), and HFRS 5.6 (IQR 3.0-8.6). The most common CirCom score was 0 + 0 (44%). Across the range of values of each index, we observed different mortality ranges: CCI 1.9-13.1%, ECI 3.2-8.7%, CirCom 4.9-13.8%, and HFRS 1.0-15.2%. An adjusted model with HFRS had the highest area under the receiver operating characteristic curve in predicting mortality (HFRS 0.782 vs. ECI 0.689, CCI 0.695, and CirCom 0.692). We observed substantial variation in mortality with HFRS within each level of CCI, ECI, and CirCom. For example, for ECI 4, mortality increased from 0.6 to 16.4%, as HFRS increased from 0 to 15. Conclusions Comorbidity indices predict inpatient cirrhosis mortality, but HFRS performs better than CCI, ECI, and CirCom. HFRS is an ideal tool for measuring comorbidity burden and disease severity risk adjustment in cirrhosis-related administrative database studies. Impact and Implications We compared commonly used comorbidity indices to a more recently described risk score (hospital frailty risk score [HFRS]) in patients with cirrhosis using a national sample of hospital records. Comorbid conditions are common in hospitalised patients with cirrhosis. There is significant variability in mortality across the range of each index. HFRS outperforms the Charlson comorbidity index, Elixhauser comorbidity index, and CirCom (cirrhosis-specific comorbidity scoring system) in predicting inpatient mortality. HFRS is a valuable index for risk adjustment in inpatient administrative database studies.
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Affiliation(s)
- Archita P. Desai
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Swetha Parvataneni
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shannon M. Knapp
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University Simon Comprehensive Cancer Center, Indianapolis, IN, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University Health, Indianapolis, IN, USA
| | - Marwan S. Ghabril
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Patidar KR, Guarnizo Ortiz M, Slaven JE, Nephew LD, Vilar Gomez E, Kettler CD, Ghabril MS, Desai AP, Orman ES, Chalasani N, Gawrieh S. Incidence, clinical characteristics, and risk factors associated with recurrent alcohol-associated hepatitis. Hepatol Commun 2023; 7:e0341. [PMID: 38055648 PMCID: PMC10984669 DOI: 10.1097/hc9.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/25/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Alcohol relapse occurs frequently in alcohol-associated hepatitis (AH) survivors, but data on the frequency and course of recurrent alcohol-associated hepatitis (rAH) are sparse. We investigated the incidence, risk factors, and outcomes of rAH. METHODS Hospitalized patients with AH from 2010 to 2020 at a large health care system were followed until death/liver transplant, last follow-up, or end of study (December 31, 2021). AH was defined by NIAAA Alcoholic Hepatitis Consortium criteria; rAH was defined a priori as a discrete AH episode >6 months from index AH hospitalization with interim >50% improvement or normalization of total bilirubin. Multivariable competing risk analysis was performed to identify factors associated with rAH. Landmark Kaplan-Meier analysis was performed to compare survival between patients who did versus those who did not develop rAH. RESULTS Of 1504 hospitalized patients with AH, 1317 (87.6%) survived and were analyzed. During a 3055 person-year follow-up, 116 (8.8%) developed rAH at an annual incidence rate of 3.8% (95% CI: 2.8-4.8). On multivariable competing risk analysis, marital status [sub-HR 0.54 (95% CI: 0.34, 0.92), p=0.01] and medications for alcohol use disorder [sub-HR 0.56 (95% CI: 0.34, 0.91), p=0.02] were associated with a lower risk for rAH. On landmark Kaplan-Meier analysis, the cumulative proportion surviving at 1 year (75% vs. 90%) and 3 years (50% vs. 78%) was significantly lower in patients who developed rAH compared to those who did not develop rAH (log-rank p<0.001). CONCLUSIONS rAH develops in ~1 in 10 AH survivors and is associated with lower long-term survival. Medications for alcohol use disorder lower the risk for rAH and, therefore, could be a key preventative strategy to improve outcomes.
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Affiliation(s)
- Kavish R. Patidar
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Maria Guarnizo Ortiz
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - James E. Slaven
- Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, Indiana, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eduardo Vilar Gomez
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Carla D. Kettler
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan S. Ghabril
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Archita P. Desai
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
| | - Samer Gawrieh
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Kashani KB, Koyner JL. Digital health utilities in acute kidney injury management. Curr Opin Crit Care 2023; 29:542-550. [PMID: 37861196 PMCID: PMC11285742 DOI: 10.1097/mcc.0000000000001105] [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: 10/21/2023]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) is a highly prevalent clinical syndrome that substantially impacts patient outcomes. It is accepted by the clinical communities that the management of AKI is time-sensitive. Unfortunately, despite growing proof of its preventability, AKI management remains suboptimal in community, acute care, and postacute care settings. Digital health solutions comprise various tools and models to improve care processes and patient outcomes in multiple medical fields. AKI development, progression, recovery, or lack thereof, offers tremendous opportunities for developing, validating, and implementing digital health solutions in multiple settings. This article will review the definitions and components of digital health, the characteristics of AKI that allow digital health solutions to be considered, and the opportunities and threats in implementing these solutions. RECENT FINDINGS Over the past two decades, the academic output related to the use of digital health solutions in AKI has exponentially grown. While this indicates the growing interest in the topic, most topics are primarily related to clinical decision support by detecting AKI within hospitals or using artificial intelligence or machine learning technologies to predict AKI within acute care settings. However, recently, projects to assess the impact of digital health solutions in more complex scenarios, for example, managing nephrotoxins among adults of pediatric patients who already have AKI, is increasing. Depending on the type of patients, chosen digital health solution intervention, comparator groups, and selected outcomes, some of these studies showed benefits, while some did not indicate additional gain in care processes or clinical outcomes. SUMMARY Careful needs assessment, selection of the correct digital health solution, and appropriate clinical validation of the benefits while avoiding additional health disparities are moral, professional, and ethical obligations for all individuals using these healthcare tools, including clinicians, data scientists, and administrators.
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Affiliation(s)
- Kianoush B. Kashani
- Division of Nephrology and Hypertension, University of Chicago, Chicago, Illinois, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, University of Chicago, Chicago, Illinois, USA
| | - Jay L. Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
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Gong YQ, Zhao Y, Jia YH, Li M, Jiang Y. Diagnostic value of combined detection of urine NGAL, KIM-1, and TFF3 in acute tubular necrosis associated with cirrhosis. Shijie Huaren Xiaohua Zazhi 2023; 31:808-815. [DOI: 10.11569/wcjd.v31.i19.808] [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: 08/16/2023] [Revised: 09/04/2023] [Accepted: 09/18/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication of decompensated cirrhosis with high clinical mortality and poor prognosis, of which acute tubular necrosis (ATN) has the worst prognosis. Timely and accurate identification of ATN is a difficult problem to solve clinically. Previous studies have shown that urinary neutrophil gelatinase-associated lipocalin (NGAL), trefoil factor 3 (TFF3), and kidney injury molecule-1 (KIM-1) have potential value in the differential diagnosis of ATN and other types of AKI in patients with liver cirrhosis, but they still cannot be applied in clinical practice due to the low diagnostic efficacy. It is necessary to further explore whether the combined detection of the indicators can improve their diagnostic efficacy for ATN associated with cirrhosis.
AIM To analyze the value of urinary NGAL, KIM-1, and TFF3, either alone or in combination, in the differential diagnosis of ATN in patients with cirrhosis complicated with AKI, and explore the cut-off values of urinary NGAL and other indicators in the differential diagnosis of ATN.
METHODS A total of 190 patients with decompensated cirrhosis were selected, including 108 patients with AKI. They were divided into different subgroups according to the cause of AKI, including 33 cases of prerenal azotemia, 27 cases of acute renal injury with hepatorenal syndrome, and 48 cases of ATN. The value of urinary NGAL, TFF3, and KIM-1, either alone or in combination, in the differential diagnosis of ATN in patients with cirrhosis complicated with AKI was then assessed.
RESULTS Urinary NGAL was of great value in the differential diagnosis of ATN in patients with cirrhosis complicated with AKI. The area under the curve (AUC) was 0.902; when the diagnostic threshold was 271.8 μg/g Cr, the sensitivity was 81.3% and the specificity was 85.0%. The combination of two biomarkers could improve the efficacy of differential diagnosis, with the diagnostic perfomance of urinary NGAL combined with urinary TFF3 being the best (AUC = 0.933, sensitivity 85.4%, specificity 88.3%).
CONCLUSION Urinary NGAL, KIM-1, and TFF3 are of great value in differentiating ATN from other types of AKI in patients with cirrhosis. The combined detection of any two of these biomarkers can further improve the diagnostic efficiency, which is worthy of further study and clinical promotion.
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Affiliation(s)
- Yan-Qing Gong
- Department of Gastroenterology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Ying Zhao
- Department of Gastroenterology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Yan-Hui Jia
- Laboratory Department, Tianjin Third Central Hospital, Tianjin 300100, China
| | - Man Li
- Department of Gastroenterology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Yong Jiang
- Department of Gastroenterology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China
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20
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Gong YQ, Zhao Y, Jia YH, Li M, Jiang Y. Role of urine/serum NGAL ratio in differential diagnosis of acute kidney injury in patients with cirrhosis. Shijie Huaren Xiaohua Zazhi 2023; 31:630-637. [DOI: 10.11569/wcjd.v31.i15.630] [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: 07/02/2023] [Revised: 07/21/2023] [Accepted: 08/03/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND Neutrophil gelatinase-associated lipocalin (NGAL) can be used for the differential diagnosis of acute kidney necrosis (ATN) and other types of acute kidney injury (AKI) in patients with liver cirrhosis complicated with AKI. However, serum NGAL is directly related to urine NGAL, and there are few existing studies on the role of urine /serum NGAL ratio in the differential diagnosis of ATN.
AIM To assess the significance of serum and urine NGAL as well as urine/serum NGAL ratio in differentiating ATN from other types of AKI in cirrhosis.
METHODS A total of 180 patients with decompensated cirrhosis were included in the study, of whom 98 were complicated with AKI. According to the etiology of AKI, there were 33 patients with prerenal azotemia, 25 with hepatorenal syndrome-AKI, and 40 with ATN. The patients were divided into different subgroups to assess the value of NGAL in differentiating the types of AKI.
RESULTS Urine NGAL and urine/serum NGAL ratio showed signi-ficant value in the differential diagnosis of ATN in patients with liver cirrhosis. At an optimal cut-off of 271.35 ng/mL, urine NGAL distinguished ATN from other types of AKI (area under the cuve [AUC] = 0.964; sensitivity, 87.5%; specificity, 96.6%). As well, at an optimal cut-off of 2.96, urine/serum NGAL ratio could also distinguish ATN from other types of AKI (AUC = 0.953, sensitivity 92.5% and specificity 91.4%).
CONCLUSION Urine NGAL and urine/serum NGAL ratio have significant value in the differential diagnosis of ATN and other types of AKI in patients with liver cirrhosis, which is worthy of further study and clinical promotion.
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Affiliation(s)
- Yan-Qing Gong
- Department of Gastroenterology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Ying Zhao
- Department of Gastroenterology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Yan-Hui Jia
- Laboratory Department, Tianjin Third Central Hospital, Tianjin 300100, China
| | - Man Li
- Department of Gastroenterology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Yong Jiang
- Department of Gastroenterology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China
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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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22
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Nephew LD, Knapp SM, Mohamed KA, Ghabril M, Orman E, Patidar KR, Chalasani N, Desai AP. Trends in Racial and Ethnic Disparities in the Receipt of Lifesaving Procedures for Hospitalized Patients With Decompensated Cirrhosis in the US, 2009-2018. JAMA Netw Open 2023; 6:e2324539. [PMID: 37471085 PMCID: PMC10359964 DOI: 10.1001/jamanetworkopen.2023.24539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 06/04/2023] [Indexed: 07/21/2023] Open
Abstract
Importance Patients with decompensated cirrhosis are hospitalized for acute management with temporizing and lifesaving procedures. Published data to inform intervention development in this area are more than a decade old, and it is not clear whether there have been improvements in disparities in the receipt of these procedures over time. Objective To evaluate the associations of race and ethnicity with receipt of procedures to treat decompensated cirrhosis over time in the US. Design, Setting, and Participants This retrospective cross-sectional study analyzed National Inpatient Sample data on cirrhosis admissions among patients with portal hypertension-related complications from 2009 to 2018. All hospital discharges for individuals aged 18 years and older from 2009 to 2018 were assessed for inclusion. Admissions were included if they contained at least 1 cirrhosis-related International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code and at least 1 cirrhosis-related complication ICD-9-CM or ICD-10-CM code (ie, ascites, hepatic encephalopathy, variceal hemorrhage [VH], and hepatorenal syndrome [HRS]). Data were analyzed from January to June 2022. Exposure Hospitalization for decompensated cirrhosis. Main Outcomes and Measures The outcomes of interest were trends in the odds ratios (ORs) for receiving procedures (upper endoscopy, transjugular portosystemic shunt [TIPS], hemodialysis, and liver transplantation [LT]) for decompensated cirrhosis and mortality by race and ethnicity, modeled over time. Multivariable logistic regression was used to assess these outcomes. Results Among 717 580 admissions (median [IQR] age, 58 [52-67] years), 345 644 patients (9.8%) were Black, 623 991 patients (17.6%) were Hispanic, and 2 340 031 patients (47.4%) were White. Based on the modeled trends, by 2018, there were no significant differences by race or ethnicity in the odds of receiving upper endoscopy for VH. However, Black patients remained less likely than White patients to undergo TIPS for VH (OR, 0.54; 95% CI, 0.47-0.62) and ascites (OR, 0.34; 95% CI, 0.31-0.38). The disparity in receipt of LT improved for Black and Hispanic patients over the study period; however, by 2018, both groups remained less likely to undergo LT than their White counterparts (Black: OR, 0.66; 95% CI, 0.61-0.70; Hispanic: OR, 0.74; 95% CI, 0.70-0.78). The odds of death in Black and Hispanic patients declined over the study period but remained higher in Black patients than White patients in 2018 (OR, 1.08; 95% CI, 1.05-1.11). Conclusions and Relevance In this cross-sectional study of individuals hospitalized with decompensated cirrhosis, there were racial and ethnic disparities in receipt of complex lifesaving procedures and in mortality that persisted over time.
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Affiliation(s)
- Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
- Indiana University Simon Comprehensive Cancer Center, Indianapolis
| | - Shannon M. Knapp
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Kawthar A. Mohamed
- Division of Medicine, University of Minnesota School of Medicine, Minneapolis
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Eric Orman
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Kavish R. Patidar
- Section of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
- Indiana University Simon Comprehensive Cancer Center, Indianapolis
| | - Archita P. Desai
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
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Abstract
Hepatorenal syndrome (HRS) is a primarily functional form of acute kidney injury (AKI) that develops in patients with decompensated cirrhosis. The pathophysiologic cascade that leads to HRS begins with pooling of blood in the splanchnic system, resulting in a decrease in effective circulating arterial volume. The definitive treatment of HRS is liver transplantation. When this is not possible, HRS is treated with a combination of vasoconstrictor agents and intravenous albumin. Although the combination of midodrine and octreotide is used in the United States, the recently approved terlipressin, an analog of vasopressin, is likely to become the first-line standard of care.
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Affiliation(s)
- Justin M Belcher
- Section of Nephrology, Yale University School of Medicine, VA Connecticut Healthcare System, VA Connecticut Healthcare, Room G126B, 950 Campbell Avenue, West Haven, CT 06516, USA.
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Gonzalez SA, Farfan Ruiz AC, Ibrahim RM, Wadei HM. Essentials of Liver Transplantation in the Setting of Acute Kidney Injury and Chronic Kidney Disease. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:356-367. [PMID: 37657882 DOI: 10.1053/j.akdh.2023.06.004] [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: 12/15/2022] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 09/03/2023]
Abstract
Kidney dysfunction is common among liver transplant candidates with decompensated cirrhosis and has a major impact on pre- and post-liver transplant survival. Updated definitions of acute kidney injury and criteria for the diagnosis of hepatorenal syndrome allow for early recognition and intervention, including early initiation of vasoconstrictor therapy for hepatorenal syndrome. The rise of the metabolic syndrome and nonalcoholic fatty liver disease as a cause of cirrhosis has coincided with an increase in intrinsic chronic kidney disease recognized in transplant candidates and recipients. Ultimately, the ability to accurately assess kidney function and associated risk is essential to decision-making in the context of transplantation, including selection of candidates for simultaneous liver and kidney transplantation.
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Affiliation(s)
- Stevan A Gonzalez
- Division of Hepatology, Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White All Saints Medical Center Fort Worth and Baylor University Medical Center Dallas, TX; Department of Medicine, Burnett School of Medicine at TCU, Fort Worth, TX.
| | - Ana Cecilia Farfan Ruiz
- Division of Transplant Nephrology, Department of Transplant, Mayo Clinic College of Medicine and Science, Jacksonville, FL
| | - Ramez M Ibrahim
- Division of Transplant Nephrology, Department of Transplant, Mayo Clinic College of Medicine and Science, Jacksonville, FL
| | - Hani M Wadei
- Division of Transplant Nephrology, Department of Transplant, Mayo Clinic College of Medicine and Science, Jacksonville, FL
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Cooper KM, Colletta A, Moulton K, Ralto KM, Devuni D. Kidney disease in patients with chronic liver disease: Does sex matter? World J Clin Cases 2023; 11:3980-3992. [PMID: 37388789 PMCID: PMC10303604 DOI: 10.12998/wjcc.v11.i17.3980] [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: 03/21/2023] [Revised: 04/30/2023] [Accepted: 05/16/2023] [Indexed: 06/12/2023] Open
Abstract
Kidney disease in patients with liver disease is serious and increases mortality. Up to 50% of patients hospitalized experience an episode of acute kidney injury. In general, men with liver disease are thought to be at increased risk of kidney disease. However, this association should be considered with caution because most studies use creatinine-based inclusion criteria, which is negatively biased against women. In this review, we synthesize data on sex differences in kidney disease in patients with chronic liver disease in the clinical setting and discuss potential physiologic underpinnings.
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Affiliation(s)
- Katherine M Cooper
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Alessandro Colletta
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Kristen Moulton
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Kenneth M Ralto
- Department of Medicine, Division of Renal Medicine, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Deepika Devuni
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01665, United States
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Patidar KR, Naved MA, Kabir S, Grama A, Allegretti AS, Cullaro G, Asrani SK, Worden A, Desai AP, Ghabril MS, Nephew LD, Orman ES. Longer time to recovery from acute kidney injury is associated with major adverse kidney events in patients with cirrhosis. Aliment Pharmacol Ther 2023; 57:1397-1406. [PMID: 36883210 PMCID: PMC10441172 DOI: 10.1111/apt.17457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/27/2022] [Accepted: 02/25/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND In patients with cirrhosis and acute kidney injury (AKI), longer time to AKI-recovery may increase the risk of subsequent major-adverse-kidney-events (MAKE). AIMS To examine the association between timing of AKI-recovery and risk of MAKE in patients with cirrhosis. METHODS Hospitalised patients with cirrhosis and AKI (n = 5937) in a nationwide database were assessed for time to AKI-recovery and followed for 180-days. Timing of AKI-recovery (return of serum creatinine <0.3 mg/dL of baseline) from AKI-onset was grouped by Acute-Disease-Quality-Initiative Renal Recovery consensus: 0-2, 3-7, and >7-days. Primary outcome was MAKE at 90-180-days. MAKE is an accepted clinical endpoint in AKI and defined as the composite outcome of ≥25% decline in estimated-glomerular-filtration-rate (eGFR) compared with baseline with the development of de-novo chronic-kidney-disease (CKD) stage ≥3 or CKD progression (≥50% reduction in eGFR compared with baseline) or new haemodialysis or death. Landmark competing-risk multivariable analysis was performed to determine the independent association between timing of AKI-recovery and risk of MAKE. RESULTS 4655 (75%) achieved AKI-recovery: 0-2 (60%), 3-7 (31%), and >7-days (9%). Cumulative-incidence of MAKE was 15%, 20%, and 29% for 0-2, 3-7, >7-days recovery groups, respectively. On adjusted multivariable competing-risk analysis, compared to 0-2-days, recovery at 3-7 and >7-days was independently associated with an increased risk for MAKE: sHR 1.45 (95% CI 1.01-2.09, p = 0.042), sHR 2.33 (95% CI 1.40-3.90, p = 0.001), respectively. CONCLUSION Longer time to recovery is associated with an increased risk of MAKE in patients with cirrhosis and AKI. Further research should examine interventions to shorten AKI-recovery time and its impact on subsequent outcomes.
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Affiliation(s)
- Kavish R. Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mobasshir A. Naved
- Department of Computer Science, Purdue University, West Lafayette, Indiana, USA
| | - Shaowli Kabir
- College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Ananth Grama
- Department of Computer Science, Purdue University, West Lafayette, Indiana, USA
| | - Andrew S. Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Giuseppe Cullaro
- Division of Gastroenterology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | | | - Astin Worden
- Division of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Archita P. Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan S. Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Johnson AW, Golzarri Arroyo L, Mahendraker N, Hosty J, Kroenke K. Hospital Opioid Usage and Adverse Events in Patients With End-Stage Liver Disease. J Pain Symptom Manage 2023; 65:326-334.e2. [PMID: 36496114 DOI: 10.1016/j.jpainsymman.2022.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/21/2022] [Accepted: 11/26/2022] [Indexed: 12/13/2022]
Abstract
CONTEXT Patients with end-stage liver disease (ESLD) commonly experience pain and other symptoms that result in a poor quality of life. Few studies have examined opioid usage, adverse events (AEs), and other outcomes in ESLD patients receiving opioid analgesia. OBJECTIVES This study aimed to compare outcomes in ESLD patients who received opioids to those who did not and to determine risk factors for AEs. METHODS This was a retrospective case-cohort study of 270 hospitalized patients with ESLD that used administrative and clinical data from the electronic medical record. RESULTS Two-thirds of patients with ESLD admitted during the study period received at least one opioid analgesic. Patients who received opioids presented with a greater number of liver related complications and higher rates of anxiety (32% vs. 17%, P= 0.007), had substantially worse initial and average pain scores (both P< 0.001), and received more palliative care consultations. The opioid group had somewhat more respiratory (22.2% vs. 11.1%, P= 0.02) and gastrointestinal (38.5% vs. 25.2%, P= 0.03) AEs, but no increase in CNS adverse events which included hepatic encephalopathy. Anxiety and disease severity (i.e., the number of liver related complications) but not opioid administration were risk factors for the number of AEs. CONCLUSION Opioid administration was not an independent risk factor for the number of AEs in hospitalized patients with ESLD, whereas anxiety and more liver-related complications increased AE risk. Our findings suggest that opioids have an appropriate and reasonably safe role in alleviation of pain in patients with ESLD.
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Affiliation(s)
- Amy W Johnson
- Division of General Internal Medicine and Geriatrics (A.W.J,N.M.,K.K.), Indianapolis.
| | - Lilian Golzarri Arroyo
- Department of Epidemiology and Biostatistics (L.G-A), School of Public Health, Bloomington
| | - Neetu Mahendraker
- Division of General Internal Medicine and Geriatrics (A.W.J,N.M.,K.K.), Indianapolis
| | - Jack Hosty
- Indiana University School of Medicine (J.H.), Indianapolis
| | - Kurt Kroenke
- Division of General Internal Medicine and Geriatrics (A.W.J,N.M.,K.K.), Indianapolis; Regenstrief Institute, Inc. (K.K.), Indianapolis, Indianapolis USA
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Acute kidney injury development and impact on clinical and economic outcomes in patients with cirrhosis: an observational cohort study over a 10-year period. Eur J Gastroenterol Hepatol 2023; 35:497-504. [PMID: 36719822 DOI: 10.1097/meg.0000000000002520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Acute kidney injury (AKI) is a severe complication that is associated with significant morbidity and mortality in hospitalized cirrhotic patients. Data about AKI incidence and outcomes in patients with cirrhosis is scarce in the Middle East region. This study explored the incidence and impact of AKI on clinical and economic outcomes in cirrhosis. METHODS This was a retrospective cohort study of cirrhosis patients admitted to an educational hospital in Jordan during the years 2012-2022. Demographics, clinical and biochemical information, and charges were retrieved from medical electronic records. Logistic regression models were conducted to evaluate predictors of AKI and mortality in cirrhosis adjusting for covariates. Hospital charges were also described. RESULTS A total of 380 cirrhosis patients were included with an AKI incidence of 27.9%. Male sex, elevated baseline serum creatinine, presence of spontaneous bacterial peritonitis, and higher comorbidity score were independently associated with AKI development ( P < 0.05). The hospital mortality rate was markedly higher for patients with AKI versus those without AKI (51.9% vs. 6.2%, respectively; P < 0.001). AKI was associated independently with higher odds of hospital death (OR = 5.83, P < 0.001), prolongation of the median hospital stays by 5 days ( P < 0.001), more clinical complications, and increased total hospital charges per admission by $2500. CONCLUSION AKI is prevalent in cirrhosis patients, and it is associated with increased mortality, hospitalization, and cost. This burden in cirrhosis emphasizes the need for early identification of patients at high risk of AKI and applying prompt and effective management approaches, aiming at improving outcomes.
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Devarbhavi H, Asrani SK, Arab JP, Nartey YA, Pose E, Kamath PS. Global burden of Liver Disease: 2023 Update. J Hepatol 2023:S0168-8278(23)00194-0. [PMID: 36990226 DOI: 10.1016/j.jhep.2023.03.017] [Citation(s) in RCA: 244] [Impact Index Per Article: 244.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 03/06/2023] [Accepted: 03/09/2023] [Indexed: 03/31/2023]
Abstract
Liver disease accounts for 2 million deaths and is responsible for 4% of all deaths (1 out of every 25 deaths worldwide); approximately 2/3 of all liver related deaths occur in men. Deaths are largely attributable to complications of cirrhosis and hepatocellular carcinoma, with acute hepatitis accounting for a smaller proportion of deaths. The most common causes of cirrhosis worldwide are related to viral hepatitis, alcohol, and nonalcoholic fatty liver disease (NAFLD). Hepatotropic viruses are the etiological factor in most cases of acute hepatitis, but drug-induced liver injury increasingly accounts for a significant proportion of cases. This iteration of the global burden of liver disease is an update of the 2019 version and focuses mainly on areas where significant new information is available like alcohol-associated liver disease, NAFLD, viral hepatitis, and HCC. We also devote a separate section to the burden of liver disease in Africa, an area of the world typically neglected in such documents.
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Affiliation(s)
- Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - Sumeet K Asrani
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX, United States.
| | - Juan Pablo Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada; Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Yvonne Ayerki Nartey
- Department of Internal Medicine, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Elisa Pose
- Liver Unit, Hospital Clinic of Barcelona. Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)
| | - Patrick S Kamath
- Mayo Clinic College of Medicine and Science, Rochester, MN, United States
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30
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Worden A, Pike F, Allegretti AS, Kaur H, Peng JL, Kettler CD, Orman ES, Desai AP, Nephew LD, Ghabril MS, Patidar KR. The prognostic impact of acute kidney injury recovery patterns in critically ill patients with cirrhosis. Liver Transpl 2023; 29:246-258. [PMID: 36811876 PMCID: PMC10068809 DOI: 10.1097/lvt.0000000000000008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/11/2022] [Indexed: 02/24/2023]
Abstract
BACKGROUND The prognostic impact of acute kidney injury (AKI) recovery patterns in critically ill patients with cirrhosis is unknown. We aimed to compare mortality stratified by AKI recovery patterns and identify predictors of mortality in patients with cirrhosis and AKI admitted to the intensive care unit. MATERIALS AND METHODS Patients with cirrhosis and AKI from 2016 to 2018 at 2 tertiary care intensive care units were analyzed (N=322). AKI recovery was defined by Acute Disease Quality Initiative consensus: return of serum creatinine <0.3 mg/dL of baseline within 7 days of AKI onset. Recovery patterns were categorized by Acute Disease Quality Initiative consensus: 0-2 days, 3-7 days, and no-recovery (persistence of AKI >7 d). Landmark competing risk univariable and multivariable models (liver transplant as competing risk) was used to compare 90-day mortality between AKI recovery groups and to determine independent predictors of mortality. RESULTS Sixteen percent (N=50) and 27% (N=88) achieved AKI recovery within 0-2 and 3-7 days, respectively; 57% (N=184) had no-recovery. Acute on chronic liver failure was prevalent (83%) and patients with no-recovery were more likely to have grade 3 acute on chronic liver failure (N=95, 52%) compared to patients with AKI recovery [0-2: 16% (N=8); 3-7: 26% (N=23); p<0.001]. Patients with no-recovery had significantly higher probability of mortality [unadjusted-sub-HR (sHR): 3.55; 95% CI: 1.94-6.49; p<0.001] compared to patients with recovery within 0-2 days, while the probability was similar between 3-7 and 0-2 days (unadjusted-sub-HR: 1.71; 95% CI: 0.91-3.20; p=0.09). On multivariable analysis, AKI no-recovery (sub-HR: 2.07; 95% CI: 1.33-3.24; p=0.001), severe alcohol-associated hepatitis (sub-HR: 2.41; 95% CI: 1.20-4.83; p=0.01), and ascites (sub-HR: 1.60; 95% CI: 1.05-2.44; p=0.03) were independently associated with mortality. CONCLUSION AKI no-recovery occurs in over half of critically ill patients with cirrhosis and AKI and is associated with worse survival. Interventions that facilitate AKI recovery may improve outcomes in this patient population.
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Affiliation(s)
- Astin Worden
- Division of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Francis Pike
- Department of Biostatistics, Indiana University, Indianapolis, Indiana, USA
| | - Andrew S. Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Harleen Kaur
- Division of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jennifer L. Peng
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Carla D. Kettler
- Department of Biostatistics, Indiana University, Indianapolis, Indiana, USA
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Archita P. Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan S. Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kavish R. Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Affiliation(s)
- Mitra K Nadim
- From the Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles (M.K.N.); and the Section of Digestive Diseases, Yale University School of Medicine, New Haven, and the Section of Digestive Diseases, Veterans Affairs Connecticut Healthcare System, West Haven - both in Connecticut (G.G.-T.)
| | - Guadalupe Garcia-Tsao
- From the Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles (M.K.N.); and the Section of Digestive Diseases, Yale University School of Medicine, New Haven, and the Section of Digestive Diseases, Veterans Affairs Connecticut Healthcare System, West Haven - both in Connecticut (G.G.-T.)
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Feng LH, Lu Y, Ren S, Liang H, Wei L, Jiang J. Development and validation of a dynamic online nomogram for predicting acute kidney injury in cirrhotic patients upon ICU admission. Front Med (Lausanne) 2023; 10:1055137. [PMID: 36778740 PMCID: PMC9911427 DOI: 10.3389/fmed.2023.1055137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/13/2023] [Indexed: 01/28/2023] Open
Abstract
Background Acute kidney injury (AKI) is one of the most common and deadly complications among cirrhotic patients at intensive care unit (ICU) admission. We aimed to develop and validate a simple and clinically useful dynamic nomogram for predicting AKI in cirrhotic patients upon ICU admission. Methods We analyzed the admission data of 4,375 patients with liver cirrhosis in ICU from 2008 to 2019 in the intensive care unit IV (MIMIC-IV) database. The eligible cirrhotic patients were non-randomly divided into derivation (n = 2,188) and validation (n = 2,187) cohorts at a ratio of 1:1, according to the order of admission. The least absolute shrinkage and selection operator regression model was used to identify independent predictors of AKI in the derivation cohort. A dynamic online nomogram was built using multivariate logistic regression analysis in the derivation cohort and then validated in the validation cohort. The C-index, calibration curve, and decision curve analysis were used to assess the nomogram's discrimination, calibration, and clinical usefulness, respectively. Results The incidence of AKI in 4,375 patients was 71.3%. Ascites, chronic kidney disease, shock, sepsis, diuretic drugs, hepatic encephalopathy, bacterial infections, vasoactive drugs, admission age, total bilirubin, and blood urea nitrogen were identified using the multivariate logistic regression analysis as significant predictors of AKI upon ICU admission. In the derivation cohort, the model showed good discrimination (C-index, 0.786; 95% CI, 0.765-0.806) and good calibration. The model in the validation cohort yielded good discrimination (C-index, 0.774; 95% CI, 0.753-0.795) and good calibration. Decision curve analysis demonstrated that the dynamic online nomogram was clinically useful. Conclusion Our study presents a dynamic online nomogram that incorporates clinical predictors and can be conveniently used to facilitate the individualized prediction of AKI in cirrhotic patients upon ICU admission.
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Affiliation(s)
- Lu-Huai Feng
- Department of Infectious Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yang Lu
- Department of Infectious Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Shuang Ren
- Department of Comprehensive Internal Medicine, The Affiliated Tumor Hospital of Guangxi Medical University, Nanning, China
| | - Hengkai Liang
- Department of Infectious Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Lu Wei
- Department of Infectious Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Jianning Jiang
- Department of Infectious Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China,*Correspondence: Jianning Jiang, ✉
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Ning Y, Zou X, Xu J, Wang X, Ding M, Lu H. Impact of acute kidney injury on the risk of mortality in patients with cirrhosis: a systematic review and meta-analysis. Ren Fail 2022; 44:1-14. [PMID: 36380739 PMCID: PMC9673785 DOI: 10.1080/0886022x.2022.2142137] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To compare the risk of mortality in patients with cirrhosis with and without the associated acute kidney injury (AKI). Methods We performed a systematic search in the PubMed, Embase, and Scopus databases for observational studies that were done on patients with cirrhosis. Eligible studies reported AKI in patients with cirrhosis and compared mortality among patients with and without AKI. We used a random-effects model, using STATA version 16.0, for deriving pooled effect sizes that were reported as odds ratio (OR) with 95% confidence intervals (CIs). Results Thirty-two studies were included. In patients with cirrhosis, AKI was significantly associated with higher in-hospital mortality (OR 5.92), and mortality at 30 days (OR 4.78), 90 days (OR 4.34), and at 1 year follow-up (OR 4.82) compared to patients without AKI. Conclusions AKI is associated with an increased risk of mortality in patients with cirrhosis. Careful monitoring to identify the development of AKI and early prompt management is necessary.
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Affiliation(s)
- Yunfeng Ning
- Department of Nephropathy, First Affiliated Hospital, Huzhou Teachers College, the First People’s Hospital of Huzhou, Huzhou, China
| | - Xiaoyue Zou
- Department of Emergency ICU, First Affiliated Hospital, Huzhou Teachers College, the First People’s Hospital of Huzhou, Huzhou, China
| | - Jing Xu
- Department of Nephropathy, First Affiliated Hospital, Huzhou Teachers College, the First People’s Hospital of Huzhou, Huzhou, China
| | - Xiao Wang
- Department of Nephropathy, First Affiliated Hospital, Huzhou Teachers College, the First People’s Hospital of Huzhou, Huzhou, China
| | - Min Ding
- Department of Nephropathy, First Affiliated Hospital, Huzhou Teachers College, the First People’s Hospital of Huzhou, Huzhou, China
| | - Hulin Lu
- Department of Nephropathy, First Affiliated Hospital, Huzhou Teachers College, the First People’s Hospital of Huzhou, Huzhou, China
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Singal AK, Kuo YF, Reddy KR, Bataller R, Kwo P. Healthcare burden and outcomes of hepatorenal syndrome among cirrhosis-related hospitalisations in the US. Aliment Pharmacol Ther 2022; 56:1486-1496. [PMID: 36196562 DOI: 10.1111/apt.17232] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/07/2022] [Accepted: 09/11/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Hepatorenal syndrome (HRS) contributes to significant morbidity and mortality in hospitalised patients with cirrhosis. AIMS To examine recent trends, magnitude and outcomes of HRS in the National Inpatient Sample (NIS) database METHODS: Among the NIS database on cirrhosis hospitalisations (2016-2019) due to alcohol (ALD), chronic viral hepatitis (CVH), or NASH and complicated by acute kidney injury (AKI) were analyzed. RESULTS Of 113,454 hospitalisations, 18,735 (16.5%) had HRS (mean age 56 years, 36% females, 68% whites, 80% ALD, 7% NASH) with a stable trend over time. Among 1:1 propensity-matched 36,090 hospitalisations, the odds of HRS were 12% higher in NASH versus CVH. Based on weighted national estimates, there were 27,180 (8.3 per 100,000 US population) HRS hospitalisations in 2019, with economic burden of $4.2 billion USD. Mean hospitalisation and total charges (ALD vs. CVH vs. NASH) were 11 versus 10.8 versus 9.2 days and 151,000 versus 157,000 versus 120,000 USD, respectively; p < 0.001. In-hospital mortality was 18.9%, higher in HRS (25.8 vs. 12%, p < 0.001), and decreased by 15% annually. Survivors were more likely to be discharged to short- or long-term care facilities (HRS vs. non-HRS [42 vs. 27%, p < 0.001]); only 28.7% received palliative care. CONCLUSION HRS was the cause of AKI in 16.5% of patients hospitalised with cirrhosis and conferred significant healthcare burden with 27,180 HRS hospitalisations in 2019 and requiring an estimated 4.2 billion USD for hospital care. While there has been a decrease in in-hospital mortality over time, it remained high at 23.7% in 2019 in those with HRS.
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Affiliation(s)
- Ashwani K Singal
- Department of Medicine, University of SD Sanford School of Medicine, Sioux Falls, South Dakota, USA.,Division of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, South Dakota, USA
| | - Yong-Fang Kuo
- Department of Biostatistics, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramon Bataller
- Division of Gastroenterology and Hepatology, UPMC, Pittsburgh, Philadelphia, USA
| | - Paul Kwo
- Division of Gastroenterology and Hepatology, Stanford University Medical School, Stanford, California, USA
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Abstract
AKI is commonly encountered in patients with decompensated cirrhosis, and it is associated with unfavorable outcomes. Among factors specific to cirrhosis, hepatorenal syndrome type 1, also referred to as hepatorenal syndrome-AKI, is the most salient and unique etiology. Patients with cirrhosis are vulnerable to traditional causes of AKI, such as prerenal azotemia, acute tubular injury, and acute interstitial nephritis. In addition, other less common etiologies of AKI specifically related to chronic liver disease should be considered, including abdominal compartment syndrome, cardiorenal processes linked to cirrhotic cardiomyopathy and portopulmonary hypertension, and cholemic nephropathy. Furthermore, certain types of GN can cause AKI in cirrhosis, such as IgA nephropathy or viral hepatitis related. Therefore, a comprehensive diagnostic approach is needed to evaluate patients with cirrhosis presenting with AKI. Management should be tailored to the specific underlying etiology. Albumin-based volume resuscitation is recommended in prerenal AKI. Acute tubular injury and acute interstitial nephritis are managed with supportive care, withdrawal of the offending agent, and, potentially, corticosteroids in acute interstitial nephritis. Short of liver transplantation, vasoconstrictor therapy is the primary treatment for hepatorenal syndrome type 1. Timing of initiation of vasoconstrictors, the rise in mean arterial pressure, and the degree of cholestasis are among the factors that determine vasoconstrictor responsiveness. Large-volume paracentesis and diuretics are indicated to relieve intra-abdominal hypertension and renal vein congestion. Direct-acting antivirals with or without immunosuppression are used to treat hepatitis B/C-associated GN. In summary, AKI in cirrhosis requires careful consideration of multiple potentially pathogenic factors and the implementation of targeted therapeutic interventions.
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Affiliation(s)
- Giuseppe Cullaro
- Department of Medicine, University of California, San Francisco, California
| | - Swetha Rani Kanduri
- Department of Nephrology, Ochsner Health, New Orleans, Louisiana
- Ochsner Clinical School, The University of Queensland, Brisbane, Queensland, Australia
| | - Juan Carlos Q. Velez
- Department of Nephrology, Ochsner Health, New Orleans, Louisiana
- Ochsner Clinical School, The University of Queensland, Brisbane, Queensland, Australia
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36
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Abstract
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.
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Affiliation(s)
- Adrià Juanola
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Catalonia, Spain
| | - Ann T Ma
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Catalonia, Spain
| | - Elisa Pose
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Catalonia, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Catalonia, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
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Cullaro G, Hsu CY, Lai JC. Variability in serum creatinine is associated with waitlist and post-liver transplant mortality in patients with cirrhosis. Hepatology 2022; 76:1069-1078. [PMID: 35357707 PMCID: PMC10321149 DOI: 10.1002/hep.32497] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/14/2022] [Accepted: 03/20/2022] [Indexed: 12/08/2022]
Abstract
BACKGROUND AND AIMS Kidney function in patients with cirrhosis is dynamic. After controlling for the presence of chronic kidney disease (CKD) and acute kidney injury (AKI), we investigated the impact of variation in clinical function on pre-liver transplantation (LT) and post-LT outcomes. APPROACH AND RESULTS We included adults listed for LT from 2011 through 2018. We excluded those with any exceptions, those on hemodialysis at listing, and those with fewer than three clinical updates in the United Network for Organ Sharing database. Our primary exposure was the serum creatinine coefficient of variation (sCr CoV). Logistic regression determined the associations between our exposures and higher sCr CoV. Competing risk regression determined the associations between our exposures and waitlist mortality, accounting for LT as a competing risk. Cox regression determined the associations between our exposures and either listing for kidney transplant or death. We divided our cohort into tertiles of sCr CoV: low variability, 8.8% (interquartile range [IQR], 6.6%-10.8%); intermediate variability, 17.4% (IQR, 14.8%-20.4%); high variability, 36.8% (IQR, 29.5%-48.8%). We demonstrate that women, those with CKD, and those with advanced liver disease were more likely to have a greater sCr CoV. Compared to those with low variability, those with high variability had significantly higher waitlist mortality (34.7% vs. 19.6% vs. 11.7%, p < 0.001). We highlight that the sCr CoV was associated with higher waitlist and post-LT mortality-an association independent of baseline sCr, the degree of underlying liver disease, the presence of AKI, or the presence of CKD. CONCLUSION This study informs the long-term impact of the variation in kidney function we all see in clinical practice. These data highlight that all fluctuations in sCr are associated with worse pre-LT and post-LT outcomes.
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Affiliation(s)
- Giuseppe Cullaro
- Department of Medicine, University of California–San Francisco, San Francisco, California, USA
| | - Chi-yuan Hsu
- Division of Nephrology, Department of Medicine, University of California–San Francisco, San Francisco, California, USA
| | - Jennifer C. Lai
- Department of Medicine, University of California–San Francisco, San Francisco, California, USA
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Patidar KR, Naved MA, Grama A, Adibuzzaman M, Aziz Ali A, Slaven JE, Desai AP, Ghabril MS, Nephew L, Chalasani N, Orman ES. Acute kidney disease is common and associated with poor outcomes in patients with cirrhosis and acute kidney injury. J Hepatol 2022; 77:108-115. [PMID: 35217065 DOI: 10.1016/j.jhep.2022.02.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS Acute kidney disease (AKD) is the persistence of acute kidney injury (AKI) for up to 3 months, which is proposed to be the time-window where critical interventions can be initiated to alter downstream outcomes of AKI. In cirrhosis, AKD and its impact on outcomes have been scantly investigated. We aimed to define the incidence and outcomes associated with AKD in a nationwide US cohort of hospitalized patients with cirrhosis and AKI. METHODS Hospitalized patients with cirrhosis and AKI in the Cerner-Health-Facts database from 1/2009-09/2017 (n = 6,250) were assessed for AKD and were followed-up for 180 days. AKI and AKD were defined based on KDIGO and ADQI AKD and renal recovery consensus criteria, respectively. The primary outcome measure was mortality, and the secondary outcome measure was de novo chronic kidney disease (CKD). Competing-risk multivariable models were used to determine the independent association of AKD with primary and secondary outcomes. RESULTS AKD developed in 32% of our cohort. On multivariable competing-risk analysis adjusting for significant confounders, patients with AKD had higher risk of mortality at 90 (subdistribution hazard ratio [sHR] 1.37; 95% CI 1.14-1.66; p = 0.001) and 180 (sHR 1.37; 95% CI 1.14-1.64; p = 0.001) days. The incidence of de novo CKD was 37.5%: patients with AKD had higher rates of de novo CKD (64.0%) compared to patients without AKD (30.7%; p <0.001). After adjusting for confounders, AKD was independently associated with de novo CKD (sHR 2.52; 95% CI 2.01-3.15; p <0.001) on multivariable competing-risk analysis. CONCLUSIONS AKD develops in 1 in 3 hospitalized patients with cirrhosis and AKI and it is associated with worse survival and de novo CKD. Interventions that target AKD may improve outcomes of patients with cirrhosis and AKI. LAY SUMMARY In a nationwide US cohort of hospitalized patients with cirrhosis and acute kidney injury, acute kidney disease developed in 1 in 3 patients and was associated with worse survival and chronic kidney disease. Interventions that target acute kidney disease may improve outcomes of patients with cirrhosis and acute kidney injury.
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Affiliation(s)
- Kavish R Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis IN, USA.
| | - Mobasshir A Naved
- Department of Computer Science, Purdue University, West Lafayette, IN USA
| | - Ananth Grama
- Department of Computer Science, Purdue University, West Lafayette, IN USA
| | - Mohammad Adibuzzaman
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health Sciences University, OR USA
| | - Arzina Aziz Ali
- Division of Internal Medicine, Indiana University School of Medicine, Indianapolis IN, USA
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis IN, USA
| | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis IN, USA
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis IN, USA
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis IN, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis IN, USA
| | - Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis IN, USA
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Association Between Kidney Dysfunction Types and Mortality Among Hospitalized Patients with Cirrhosis. Dig Dis Sci 2022; 67:3426-3435. [PMID: 34292470 PMCID: PMC9568372 DOI: 10.1007/s10620-021-07159-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 07/05/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIMS Kidney dysfunction is associated with increased mortality among patients with cirrhosis. We investigated whether kidney dysfunction types [e.g., acute kidney injury (AKI), chronic kidney disease (CKD), and AKI on CKD] were differentially associated with inpatient mortality. METHODS We utilized the nationwide inpatient sample, a nationally representative database, from 2007 to 2014. We included all hospitalizations with previously validated codes for cirrhosis or associated decompensated cirrhosis diagnoses. We defined kidney dysfunction types also from previously validated codes, and we grouped hospitalizations into the following diagnoses: normal, AKI, CKD, and AKI on CKD. Our primary outcome was inpatient mortality. RESULTS There were 1,293,779 hospitalizations with cirrhosis sampled in this study. Of these hospitalizations, 849,193 (66%) had normal kidney function, 176,418 (14%) had AKI, 157,600 (12%) had CKD, and 110,568 (9%) had AKI on CKD. We found that the proportion of hospitalizations with AKI, CKD, and AKI on CKD increased significantly throughout the study period (p < 0.001, test for trend for all). Kidney dysfunction type was differentially associated with inpatient mortality, even after adjustment: as compared to those with CKD, normal kidney function: OR 0.75 [95 CI 0.73-0.78], AKI: OR 2.40 [95 CI 2.32-2.48], and AKI on CKD: OR 1.66 [95 CI 1.60-1.72]. DISCUSSION Using a nationally representative cohort of all hospitalizations with cirrhosis, our study highlights that the burden of kidney dysfunction, especially AKI, among hospitalizations with cirrhosis is rising, and the inclusion of kidney dysfunction type may be an opportunity to improve prognostication.
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Asrani SK, Shankar N, da Graca B, Nadim MK, Cardenas A. Role of Novel Kidney Biomarkers in Patients With Cirrhosis and After Liver Transplantation. Liver Transpl 2022; 28:466-482. [PMID: 34714972 DOI: 10.1002/lt.26344] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/19/2021] [Accepted: 10/21/2021] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - Mitra K Nadim
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Andres Cardenas
- GI/Liver Transplant Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, Barcelona, Spain.,Faculty of Medicine, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
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Pacheco MP, Carneiro-D'Albuquerque LA, Mazo DF. Current aspects of renal dysfunction after liver transplantation. World J Hepatol 2022; 14:45-61. [PMID: 35126839 PMCID: PMC8790396 DOI: 10.4254/wjh.v14.i1.45] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 10/24/2021] [Accepted: 01/06/2022] [Indexed: 02/06/2023] Open
Abstract
The development of chronic kidney disease (CKD) after liver transplantation (LT) exerts a severe effect on the survival of patients. The widespread adoption of the model for end-stage liver disease score strongly impacted CKD incidence after the procedure, as several patients are transplanted with previously deteriorated renal function. Due to its multifactorial nature, encompassing pre-transplantation conditions, perioperative events, and nephrotoxic immunosuppressor therapies, the accurate identification of patients under risk of renal disease, and the implementation of preventive approaches, are extremely important. Methods for the evaluation of renal function in this setting range from formulas that estimate the glomerular filtration rate, to non-invasive markers, although no option has yet proved efficient in early detection of kidney injury. Considering the nephrotoxicity of calcineurin inhibitors (CNI) as a factor of utmost importance after LT, early nephroprotective strategies are highly recommended. They are based mainly on delaying the application of CNI during the immediate postoperative-period, reducing their dosage, and associating them with other less nephrotoxic drugs, such as mycophenolate mofetil and everolimus. This review provides a critical assessment of the causes of renal dysfunction after LT, the methods of its evaluation, and the interventions aimed at preserving renal function early and belatedly after LT.
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Affiliation(s)
- Mariana P Pacheco
- Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, Sao Paulo 05403-900, Sao Paulo, Brazil
| | - Luiz Augusto Carneiro-D'Albuquerque
- Division of Digestive Organs Transplant, Department of Gastroenterology, University of São Paulo School of Medicine, Sao Paulo 05403-900, Sao Paulo, Brazil
| | - Daniel F Mazo
- Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo School of Medicine, Sao Paulo 05403-900, Sao Paulo, Brazil
- Division of Gastroenterology, Department of Internal Medicine, School of Medical Sciences of University of Campinas, Campinas 13083-878, Sao Paulo, Brazil
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Patidar KR, Adibuzzaman M, Naved MA, Rodriquez D, Slaven JE, Grama A, Desai AP, Gomez EV, Ghabril MS, Nephew L, Samala NR, Anderson M, Chalasani NP, Orman ES. Practice patterns and outcomes associated with intravenous albumin in patients with cirrhosis and acute kidney injury. Liver Int 2022; 42:187-198. [PMID: 34779104 DOI: 10.1111/liv.15096] [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: 06/30/2021] [Accepted: 10/30/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Guidelines recommend albumin as the plasma-expander of choice for acute kidney injury (AKI) in cirrhosis. However, the impact of these recommendations on patient outcomes remains unclear. We aimed to determine the practice-patterns and outcomes associated with albumin use in a large, nationwide-US cohort of hospitalized cirrhotics with AKI. METHODS A retrospective cohort study was performed in hospitalized cirrhotics with AKI using Cerner-Health-Facts database from January 2009 to March 2018. 6786 were included for analysis on albumin-practice-patterns, and 4126 had available outcomes data. Propensity-score-adjusted model was used to determine the association between albumin use, AKI-recovery and in-hospital survival. RESULTS Median age was 61-years (60% male, 70% white), median serum-creatinine was 1.8 mg/dL and median Model for End-stage Liver Disease Sodium (MELD-Na) score was 24. Albumin was given to 35% of patients, of which 50% received albumin within 48-hours of AKI-onset, and 17% received appropriate weight-based dosing. Albumin was used more frequently in patients with advanced complications of cirrhosis, higher MELD-Na scores and patients admitted to urban-teaching hospitals. After propensity-matching and multivariable adjustment, albumin use was not associated with AKI-recovery (odds ratio [OR] 0.70, 95% confidence-interval [CI]: 0.59-1.07, P = .130) or in-hospital survival (OR 0.76 [95% CI: 0.46-1.25], P = .280), compared with crystalloids. Findings were unchanged in subgroup analyses of patients with varying cirrhosis complications and disease severity. CONCLUSIONS USA hospitalized patients with cirrhosis and AKI frequently do not receive intravenous albumin, and albumin use was not associated with improved clinical outcomes. Prospective randomised trials are direly needed to evaluate the impact of albumin in cirrhotics with AKI.
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Affiliation(s)
- Kavish R Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mohammad Adibuzzaman
- Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Mobasshir A Naved
- Department of Computer Science, Purdue University, West Lafayette, Indiana, USA
| | - Dylan Rodriquez
- Department of Computer Science, Purdue University, West Lafayette, Indiana, USA
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ananth Grama
- Department of Computer Science, Purdue University, West Lafayette, Indiana, USA
| | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eduardo V Gomez
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Niharika R Samala
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Melissa Anderson
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Naga P Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Bajaj JS, Garcia-Tsao G, Reddy KR, O’Leary JG, Vargas HE, Lai JC, Kamath PS, Tandon P, Subramanian RM, Thuluvath P, Fagan A, Sehrawat T, de la Rosa Rodriguez R, Thacker LR, Wong F. Admission Urinary and Serum Metabolites Predict Renal Outcomes in Hospitalized Patients With Cirrhosis. Hepatology 2021; 74:2699-2713. [PMID: 34002868 PMCID: PMC9338693 DOI: 10.1002/hep.31907] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Acute kidney injury (AKI) has a poor prognosis in cirrhosis. Given the variability of creatinine, the prediction of AKI and dialysis by other markers is needed. The aim of this study is to determine the role of serum and urine metabolomics in the prediction of AKI and dialysis in an inpatient cirrhosis cohort. APPROACH AND RESULTS Inpatients with cirrhosis from 11 North American Consortium of End-stage Liver Disease centers who provided admission serum/urine when they were AKI and dialysis-free were included. Analysis of covariance adjusted for demographics, infection, and cirrhosis severity was performed to identify metabolites that differed among patients (1) who developed AKI or not; (2) required dialysis or not; and/pr (3) within AKI subgroups who needed dialysis or not. We performed random forest and AUC analyses to identify specific metabolite(s) associated with outcomes. Logistic regression with clinical variables with/without metabolites was performed. A total of 602 patients gave serum (218 developed AKI, 80 needed dialysis) and 435 gave urine (164 developed AKI, 61 needed dialysis). For AKI prediction, clinical factor-adjusted AUC was 0.91 for serum and 0.88 for urine. Major metabolites such as uremic toxins (2,3-dihydroxy-5-methylthio-4-pentenoic acid [DMTPA], N2N2dimethylguanosine, uridine/pseudouridine) and tryptophan/tyrosine metabolites (kynunerate, 8-methoxykyunerate, quinolinate) were higher in patients who developed AKI. For dialysis prediction, clinical factor-adjusted AUC was 0.93 for serum and 0.91 for urine. Similar metabolites as AKI were altered here. For dialysis prediction in those with AKI, the AUC was 0.81 and 0.79 for serum/urine. Lower branched-chain amino-acid (BCAA) metabolites but higher cysteine, tryptophan, glutamate, and DMTPA were seen in patients with AKI needing dialysis. Serum/urine metabolites were additive to clinical variables for all outcomes. CONCLUSIONS Specific admission urinary and serum metabolites were significantly additive to clinical variables to predict AKI development and dialysis initiation in inpatients with cirrhosis. These observations can potentially facilitate earlier initiation of renoprotective measures.
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Affiliation(s)
- Jasmohan S. Bajaj
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA
| | | | | | | | | | | | | | | | | | | | - Andrew Fagan
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA
| | | | | | - Leroy R. Thacker
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA
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Abstract
PURPOSE OF REVIEW Hepatorenal syndrome (HRS) is encountered frequently in patients with end-stage liver disease and remains an important cause of morbidity and mortality in this patient population. This review will focus and provide updates on pathophysiology, assessment of kidney function, new definitions, and treatment and prevention of HRS. RECENT FINDINGS Pathophysiology of HRS has been elucidated more recently and in addition to hemodynamic changes, the role of systemic inflammatory response contributes significantly to this process. Assessment of kidney function in patients with liver cirrhosis remains challenging. Novel glomerular filtration rate equations have been developed in patients with liver disease to better estimate kidney function and changes made in the definition of acute kidney injury (AKI), which are more aligned with KDIGO criteria for AKI. Vasoconstrictors, especially terlipressin, along with albumin remain the mainstay of pharmacological treatment of HRS-AKI. Biomarkers have been useful in differentiating ATN from HRS at an early stage. SUMMARY HRS remains a significant cause of morbidity and mortality for patients with end-stage liver disease. Newer understanding of mechanisms in development and pathophysiology of HRS have helped with elucidation of the disease process.
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Campello E, Zanetto A, Radu CM, Bulato C, Truma A, Spiezia L, Senzolo M, Garcia-Tsao G, Simioni P. Acute kidney injury is associated with increased levels of circulating microvesicles in patients with decompensated cirrhosis. Dig Liver Dis 2021; 53:879-888. [PMID: 33431230 PMCID: PMC11090178 DOI: 10.1016/j.dld.2020.12.118] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Microvesicles (MVs) play a role in inflammation, coagulation, and vascular homeostasis in liver disease. AIM To characterize circulating plasma MVs profile in patients with decompensated cirrhosis and acute kidney injury (AKI). METHODS We measured the levels of total, endothelial, platelet, tissue factor (TF)+, leukocyte and hepatocyte MVs by new generation flow-cytometry in a prospective cohort of patients with decompensated cirrhosis with and without AKI. RESULTS Eighty patients with decompensated cirrhosis were recruited (40 each with and without AKI). Patients with cirrhosis with AKI had significantly higher calcein+ (total), endothelial, and platelet-MVs. Conversely, TF+, leukocyte, and hepatocyte-MVs were comparable between groups. Resolution of AKI was associated with significantly decreased total and endothelial-MVs that became comparable with those in patients without AKI. Platelet MVs significantly decreased but remained higher compared to patients without AKI. TF+MVs significantly decreased and became lower than patients without AKI. Leukocyte and hepatocyte-MVs remained unchanged. Creatinine (OR 4.3 [95%CI 1.8-10.7]), MELD (OR 1.13 [95%CI 1.02-1.27]), any bleeding (OR 9.07 [95%CI 2.02-40.6]), and hepatocyte-MVs (OR 1.04 [95%CI 1.02-1.07]) were independently associated with 30-day mortality. CONCLUSION AKI worsened vascular and cellular homeostasis in patients with cirrhosis, particularly by inducing endothelial dysfunction and platelet activation. AKI did not worsen systemic inflammation and hepatocytes activation.
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Affiliation(s)
- Elena Campello
- Thrombotic and Hemorrhagic Diseases Unit, General Internal Medicine, Padova University Hospital, Padova, Italy
| | - Alberto Zanetto
- Digestive Disease Section, Internal Medicine, Yale School of Medicine, New Haven, CT, USA; VA-Connecticut Healthcare System, West Haven, CT, USA; Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Claudia M Radu
- Thrombotic and Hemorrhagic Diseases Unit, General Internal Medicine, Padova University Hospital, Padova, Italy
| | - Cristiana Bulato
- Thrombotic and Hemorrhagic Diseases Unit, General Internal Medicine, Padova University Hospital, Padova, Italy
| | - Addolorata Truma
- Thrombotic and Hemorrhagic Diseases Unit, General Internal Medicine, Padova University Hospital, Padova, Italy
| | - Luca Spiezia
- Thrombotic and Hemorrhagic Diseases Unit, General Internal Medicine, Padova University Hospital, Padova, Italy
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Guadalupe Garcia-Tsao
- Digestive Disease Section, Internal Medicine, Yale School of Medicine, New Haven, CT, USA; VA-Connecticut Healthcare System, West Haven, CT, USA
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Diseases Unit, General Internal Medicine, Padova University Hospital, Padova, Italy.
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Desai AP, Greene M, Nephew LD, Orman ES, Ghabril M, Chalasani N, Menachemi N. Contemporary Trends in Hospitalizations for Comorbid Chronic Liver Disease and Substance Use Disorders. Clin Transl Gastroenterol 2021; 12:e00372. [PMID: 34142663 PMCID: PMC8216677 DOI: 10.14309/ctg.0000000000000372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/28/2021] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Chronic liver diseases (CLDs) and substance use disorders (SUDs) are increasingly prevalent and often coexist. Contemporary studies describing the characteristics and hospitalization trends of those with comorbid CLD-SUD are lacking. We aimed to characterize a population-based cohort with comorbid CLD-SUD and describe trends in these hospitalizations over time by individual-level characteristics. METHODS We performed a cross-sectional analysis of the National Inpatient Sample from 2005 through 2017. Diagnosis codes were used to identify adult hospitalizations with CLD, SUD, or both. Bivariate and multivariate analyses were used to make comparisons between diagnosis categories. Unadjusted and age-adjusted trends in these hospitalizations were described over time. RESULTS Of 401,867,749 adult hospital discharges, 3.2% had CLD-only and 1.7% had comorbid CLD-SUD. Compared with CLD-only, comorbid CLD-SUD hospitalizations resulted in higher inpatient mortality (3.1% vs 2.4%, P < 0.001) and were associated with younger age, male sex, Native American race, and urban and Western US location. Over time, comorbid hospitalizations grew 34%, and the demographics shifted with larger increases in hospitalization rates seen in younger individuals, women, Native Americans, and those publicly insured. In comorbid hospitalizations, alcoholic SUD and CLD decreased, but drug SUDs and nonalcoholic fatty liver diseases are fast-growing contributors. DISCUSSION In this comprehensive analysis of US hospitalizations, comorbid CLD-SUD hospitalizations are increasing over time and lead to higher inpatient mortality than CLD alone. We further characterize the changing demographics of these hospitalizations, providing a contemporary yet inclusive look at comorbid CLD-SUD hospitalizations. These data can guide interventions needed to improve the poor outcomes suffered by this growing population.
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Affiliation(s)
- Archita P. Desai
- Department of Gastroenterology and Hepatology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Marion Greene
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Lauren D. Nephew
- Department of Gastroenterology and Hepatology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Eric S. Orman
- Department of Gastroenterology and Hepatology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Marwan Ghabril
- Department of Gastroenterology and Hepatology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Department of Gastroenterology and Hepatology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Nir Menachemi
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
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Juanola A, Solé C, Toapanta D, Ginès P, Solà E. Monitoring Renal Function and Therapy of Hepatorenal Syndrome Patients with Cirrhosis. Clin Liver Dis 2021; 25:441-460. [PMID: 33838860 DOI: 10.1016/j.cld.2021.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Acute kidney injury (AKI) is a frequent complication in patients with cirrhosis. Patients with cirrhosis can develop AKI due to different causes. Hepatorenal syndrome (HRS) is a unique cause of AKI occurring in patients with advanced cirrhosis and is associated with high short-term mortality. The differential diagnosis between different causes of AKI may be challenging. In this regard, new urine biomarkers may be helpful. Liver transplantation is the definitive treatment of patients with HRS-AKI. Vasoconstrictors and albumin represent the first-line pharmacologic treatment of HRS-AKI. This review summarizes current knowledge for the diagnosis and management of HRS in cirrhosis.
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Affiliation(s)
- Adrià Juanola
- Liver Unit, Hospital Clínic de Barcelona, 08036 Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
| | - Cristina Solé
- Liver Unit, Hospital Clínic de Barcelona, 08036 Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - David Toapanta
- Liver Unit, Hospital Clínic de Barcelona, 08036 Barcelona, Catalonia, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clínic de Barcelona, 08036 Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.
| | - Elsa Solà
- Liver Unit, Hospital Clínic de Barcelona, 08036 Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
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Sohn W, Ham CB, Kim NH, Kim HJ, Cho YK, Jeon WK, Kim BI. Effect of acute kidney injury on the patients with hepatocellular carcinoma undergoing transarterial chemoembolization. PLoS One 2020; 15:e0243780. [PMID: 33315944 PMCID: PMC7735598 DOI: 10.1371/journal.pone.0243780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/25/2020] [Indexed: 01/13/2023] Open
Abstract
The purpose of this study was to investigate the effect of acute kidney injury (AKI) on the prognosis of patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). A total of 347 HCC patients with Child-Pugh class A and pre-TACE serum creatinine (SCr) ≤1.5 mg/dL undergoing TACE as an initial therapy 2000-2014 were analyzed. Overall survival with related risk factors including AKI was investigated. We assessed AKI based on the International Club of Ascites (ICA)-AKI criteria. The mean age was 60.9 years. Of 347 patients, death was observed in 109 patients (31.4%). The mean SCr levels at pre-TACE, one day, two months, and four months after TACE were 0.9, 0.9, 0.9, and 1.1 mg/dL, respectively. The AKI within four months after TACE developed in 37 patients (11%). The AKI stages were non-AKI in 310 (89%), stage 1 in 10 (3%), stage 2 in 10 (3%), and stage 3 in 17 patients (5%). Multivariable analysis showed that the risk factors for overall survival were serum albumin ≤3.5 g/dL (hazard ratio [HR] 1.58, p = 0.027), BCLC stage B (HR 2.07, p = 0.008), BCLC stage C (HR 3.96, p<0.001), bilobar tumor location (HR 1.66, p = 0.022), AKI stage 1 (HR 6.09, p<0.001), AKI stage 2 (HR 8.51, p<0.001), and AKI stage 3 (HR 17.64, p<0.001). AKI is a crucial prognostic factor for overall survival in HCC patients undergoing TACE. The assessment of AKI based on the ICA-AKI criteria can facilitate evaluation of the prognosis of HCC patients undergoing TACE.
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Affiliation(s)
- Won Sohn
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Cheol Bae Ham
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Nam Hee Kim
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hong Joo Kim
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yong Kyun Cho
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Woo Kyu Jeon
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byung Ik Kim
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
- * E-mail:
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49
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Wong RJ, Cheung RC. Chronic Kidney Disease in Patients with Chronic Liver Disease: What Is the Price Tag? Hepatol Commun 2020; 4:1389-1391. [PMID: 33024910 PMCID: PMC7527759 DOI: 10.1002/hep4.1583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/14/2020] [Indexed: 02/06/2023] Open
Affiliation(s)
- Robert J Wong
- Division of Gastroenterology and Hepatology Veterans Affairs Palo Alto Health Care System Palo Alto CA
- Division of Gastroenterology and Hepatology Stanford University School of Medicine Stanford CA
| | - Ramsey C Cheung
- Division of Gastroenterology and Hepatology Veterans Affairs Palo Alto Health Care System Palo Alto CA
- Division of Gastroenterology and Hepatology Stanford University School of Medicine Stanford CA
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Rustgi VK, Li Y, John T, Catalano C, Elsaid MI. Health Care Resource Use and Cost Burden of Chronic Kidney Disease in Patients With Chronic Liver Disease: A Real-World Claims Analysis. Hepatol Commun 2020; 4:1404-1418. [PMID: 33024912 PMCID: PMC7527762 DOI: 10.1002/hep4.1573] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 12/15/2022] Open
Abstract
Chronic Liver Disease (CLD) is associated with an increased risk of chronic kidney disease (CKD). However, the health care burden of CKD in the CLD spectrum is unknown. We aimed to evaluate the health care use and cost burdens associated with CKD in patients with CLD in the United States by using real-world claims data. We analyzed data from the Truven Health MarketScan Commercial Claims database from 2010 to 2015. A total of 19,664 patients with CLD with or without comorbid CKD were identified using International Classification of Diseases, Ninth Revision, codes and matched 1:1 by sociodemographic characteristics and comorbidities using propensity scores. Total and service-specific unadjusted and adjusted health care parameters were analyzed for the 12 months following an index date selected at random to capture whole disease burdens. In CLD, comorbid CKD was associated with a higher annual number of claims per person (CKD vs. no CKD, 69 vs. 55) and higher total annual median health care costs (CKD vs. no CKD, $21,397 vs. $16,995). A subanalysis stratified by CKD category showed that health care use and cost burden in CLD increased with disease stage, with a peak 12-month median cost difference of $77,859 in patients on dialysis. The adjusted per person annual health care cost was higher for CKD cases compared to controls ($35,793 vs. $24,048, respectively; P < 0.0001). Stratified by the type of CLD, the highest between-group adjusted cost differences were for cirrhosis, viral hepatitis, hemochromatosis, and nonalcoholic fatty liver disease. Conclusion: CKD is a cost multiplier in CLD. The CKD health care burden in liver disease differs by the type of CLD. Improved CKD screening and proactive treatment interventions for at-risk patients can limit the excess burden associated with CKD in patients with CLD.
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Affiliation(s)
- Vinod K. Rustgi
- Division of Gastroenterology and HepatologyRutgers Robert Wood Johnson Medical SchoolNew BrunswickNJ
- Center for Liver Diseases and MassesRutgers Robert Wood Johnson Medical SchoolNew BrunswickNJ
| | - You Li
- Division of Gastroenterology and HepatologyRutgers Robert Wood Johnson Medical SchoolNew BrunswickNJ
- Center for Liver Diseases and MassesRutgers Robert Wood Johnson Medical SchoolNew BrunswickNJ
| | - Tina John
- Division of Gastroenterology and HepatologyRutgers Robert Wood Johnson Medical SchoolNew BrunswickNJ
| | - Carolyn Catalano
- Division of Gastroenterology and HepatologyRutgers Robert Wood Johnson Medical SchoolNew BrunswickNJ
- Center for Liver Diseases and MassesRutgers Robert Wood Johnson Medical SchoolNew BrunswickNJ
| | - Mohamed I. Elsaid
- Division of Gastroenterology and HepatologyRutgers Robert Wood Johnson Medical SchoolNew BrunswickNJ
- Center for Liver Diseases and MassesRutgers Robert Wood Johnson Medical SchoolNew BrunswickNJ
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