Risk of contrast-induced nephropathy in hospitalized patients with cirrhosis

Acute kidney injury in patients with cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) joint multidisciplinary consensus meeting

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.

A prospective, multicenter, three-cohort study evaluating contrast-induced acute kidney injury (CI-AKI) in patients with cirrhosis

BACKGROUND & AIMS

Nephrotoxicity of intravenous iodinated contrast media (ICM) in cirrhosis is still a debated issue, due to scarce, low-quality and conflicting evidence. This study aims to evaluate the incidence and predisposing factors of acute kidney injury (AKI) in patients with cirrhosis undergoing contrast-enhanced computed tomography (CECT).

METHODS

We performed a prospective, multicenter, cohort study including 444 inpatients, 148 with cirrhosis (cohort 1) and 163 without cirrhosis (cohort 3) undergoing CECT and 133 with cirrhosis (cohort 2) unexposed to ICM. Kidney function parameters were assessed at T0, 48-72 h (T1), 5 and 7 days after CECT/enrollment. Urinary neutrophil gelatinase-associated lipocalin (U-NGAL) was measured in 50 consecutive patients from cohort 1 and 50 from cohort 2 as an early biomarker of tubular damage.

RESULTS

AKI incidence was not significantly increased in patients with cirrhosis undergoing CECT (4.8%, 1.5%, 2.5% in cohorts 1, 2, 3 respectively, p = n.s.). Most AKI cases were mild and transient. The presence of concomitant infections was the only independent predictive factor of contrast-induced AKI (odds ratio 22.18; 95% CI 2.87-171.22; p = 0.003). No significant modifications of U-NGAL between T0 and T1 were detected, neither in cohort 1 nor in cohort 2 (median ΔU-NGAL: +0.2 [-7.6 to +5.5] ng/ml, +0.0 [-6.8 to +9.5] ng/ml, respectively [p = 0.682]).

CONCLUSIONS

AKI risk after CECT in cirrhosis is low and not significantly different from that of the general population or of the cirrhotic population unexposed to ICM. It mostly consists of mild and rapidly resolving episodes of renal dysfunction and it is not associated with tubular kidney injury. Patients with ongoing infections appear to be the only ones at higher risk of AKI.

IMPACT AND IMPLICATIONS

Nephrotoxicity due to intravenous iodinated contrast media (ICM) in patients with cirrhosis is still a debated issue, as the available evidence is limited and based on very heterogeneous studies, often conducted on small and retrospective cohorts. In this prospective three-cohort study we found that intravenous administration of ICM was associated with a low risk of AKI, similar to that of the general population and to that of patients with cirrhosis unexposed to ICM. Patients with ongoing infections were the only ones to have a significantly increased risk of contrast-induced AKI. Therefore, the actual recommendations of performing contrast imaging studies cautiously in cirrhosis do not seem to be reasonable anymore, with the exception of infected patients, who have a significantly higher risk of contrast-induced AKI.

Acute kidney injury in patients with acute-on-chronic liver failure: clinical significance and management

Acute-on-chronic-liver failure (ACLF) refers to a phenomenon in which patients with chronic liver disease develop multiple organ failure due to acute exacerbation of underlying liver disease. More than 10 definitions of ACLF are extant around the world, and there is lack of consensus on whether extrahepatic organ failure is a main component or a consequence of ACLF. Asian and European consortiums have their own definitions of ACLF. The Asian Pacific Association for the Study of the Liver ACLF Research Consortium does not consider kidney failure as a diagnostic criterion for ACLF. Meanwhile, the European Association for the Study of the Liver Chronic Liver Failure and the North American Consortium for the Study of End-stage Liver Disease do consider kidney failure as an important factor in diagnosing and assessing the severity of ACLF. When kidney failure occurs in ACLF patients, treatment varies depending on the presence and stage of acute kidney injury (AKI). In general, the diagnosis of AKI in cirrhotic patients is based on the International Club of Ascites criteria: an increase of 0.3 mg/dL or more within 48 hours or a serum creatinine increase of 50% or more within one week. This study underscores the importance of kidney failure or AKI in patients with ACLF by reviewing its pathophysiology, prevention methods, and treatment approaches.

Position paper on liver and kidney diseases from the Italian Association for the Study of Liver (AISF), in collaboration with the Italian Society of Nephrology (SIN)

Liver and kidney are strictly connected in a reciprocal manner, in both the physiological and pathological condition. The Italian Association for the Study of Liver, in collaboration with the Italian Society of Nephrology, with this position paper aims to provide an up-to-date overview on the principal relationships between these two important organs. A panel of well-recognized international expert hepatologists and nephrologists identified five relevant topics: 1) The diagnosis of kidney damage in patients with chronic liver disease; 2) Acute kidney injury in liver cirrhosis; 3) Association between chronic liver disease and chronic kidney disease; 4) Kidney damage according to different etiology of liver disease; 5) Polycystic kidney and liver disease. The discussion process started with a review of the literature relating to each of the five major topics and clinical questions and related statements were subsequently formulated. The quality of evidence and strength of recommendations were graded according to the GRADE system. The statements presented here highlight the importance of strong collaboration between hepatologists and nephrologists for the management of critically ill patients, such as those with combined liver and kidney impairment.

INASL-ISN Joint Position Statements on Management of Patients with Simultaneous Liver and Kidney Disease

Renal dysfunction is very common among patients with chronic liver disease, and concomitant liver disease can occur among patients with chronic kidney disease. The spectrum of clinical presentation and underlying etiology is wide when concomitant kidney and liver disease occur in the same patient. Management of these patients with dual onslaught is challenging and requires a team approach of hepatologists and nephrologists. No recent guidelines exist on algorithmic approach toward diagnosis and management of these challenging patients. The Indian National Association for Study of Liver (INASL) in association with Indian Society of Nephrology (ISN) endeavored to develop joint guidelines on diagnosis and management of patients who have simultaneous liver and kidney disease. For generating these guidelines, an INASL-ISN Taskforce was constituted, which had members from both the societies. The taskforce first identified contentious issues on various aspects of simultaneous liver and kidney diseases, which were allotted to individual members of the taskforce who reviewed them in detail. A round-table meeting of the Taskforce was held on 20-21 October 2018 at New Delhi to discuss, debate, and finalize the consensus statements. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications. The strength of recommendations (strong and weak) thus reflects the quality (grade) of underlying evidence (I, II, III). We present here the INASL-ISN Joint Position Statements on Management of Patients with Simultaneous Liver and Kidney Disease.

Contrast-induced acute kidney injury following coronary angiography in patients with end-stage liver disease

Background: Contrast-induced acute kidney injury (CIAKI) following coronary angiography is frequently observed in the general population. End-stage liver disease (ESLD) patients are at a particularly increased risk for development of CIAKI following coronary angiography due to preexisting renal hypoperfusion.

Methods: We performed a retrospective study of 544 consecutive cardiac catheterizations in ESLD patients from December 2003 to May 2013 to calculate the incidence of CIAKI post-coronary angiography and to identify risk factors for CIAKI. CIAKI was defined as a serum creatinine increase of either ≥ 25% or ≥ 0.5 mg/dL from baseline within 72 hours. Multivariable and Cox regression analysis was performed for development of CIAKI and all-cause mortality, respectively.

Results: Overall, 179 cases of coronary angiography were included in the final analysis. CIAKI occurred in 23% of patients. All-cause mortality was 52% in the CIAKI group and 37% in the non-CIAKI group, with a mean follow-up of 2.2 ± 3.8 years. Multivariable analysis identified intensive care unit admission (OR 2.72, CI 1.05–7.01, p < 0.05) and baseline estimated glomerular filtration rate (OR 1.02, CI 1.002–1.035, p < 0.05) as independent predictors of CIAKI. Cox regression analysis identified pre-angiography beta-blocker use (HR 2.13, CI 1.04–4.38, p < 0.05), international normalized ratio (HR 1.37, CI 1.05–1.78, p < 0.05) and Mehran risk score (HR 1.13, CI 1.02–1.25, p < 0.05) as independent predictors of all-cause mortality.

Conclusions: CIAKI in ESLD patients undergoing coronary angiography occurs at a moderately elevated rate when compared to the general population.

Acute kidney injury after platinum-based transcatheter arterial chemoembolization and transarterial infusion chemotherapy in patients with hepatocellular carcinoma

Backgrounds

The incidence of acute kidney injury and the association between acute kidney injury and prognosis have been reported about transcatheter arterial chemoembolization using anthracycline. However, the incidence of acute kidney injury after platinum-based transarterial chemoembolization or transarterial infusion chemotherapy remains unclear. The aim of this study was to investigate association between acute kidney injury after platinum-based transcatheter arterial chemoembolization/transarterial infusion chemotherapy and prognosis in patients with hepatocellular carcinoma.

Methods

We retrospectively analysed 270 sessions in 129 patients who underwent platinum-based transcatheter arterial chemoembolization/transarterial infusion chemotherapy. Acute kidney injury was diagnosed according to the criteria established by the International Club of Ascites. The incidence of acute kidney injury, risk factors for serum creatinine elevation and association between acute kidney injury and prognosis were assessed.

Results

Fifteen cases of acute kidney injury (5.6%, 15/270) developed in 14 patients (10.8%, 14/129). Ascites (coefficient: 0.059, P = 0.006), low estimated glomerular filtration rate (coefficient: −0.008, P = 0.029), diabetes (coefficient: 0.072, P &lt; 0.001) and high albumin–bilirubin grade (albumin–bilirubin grade 2: coefficient: 0.053, P = 0.004; and albumin–bilirubin grade 3: coefficient: 0.103, P &lt; 0.001) were significantly associated with an elevation in serum creatinine levels after transcatheter arterial chemoembolization/transarterial infusion chemotherapy. The development of acute kidney injury was associated with poor prognosis (hazard ratio: 3.18, 95%CI: 1.411–7.171, P = 0.005). Patients with acute kidney injury had a significantly lower survival rate than patients without acute kidney injury (log-rank test; P = 0.034).

Conclusions

The incidence of acute kidney injury after platinum-based transcatheter arterial chemoembolization/transarterial infusion chemotherapy was consistent with that after transcatheter arterial chemoembolization using anthracycline, and the development of acute kidney injury was associated with poor prognosis. Ascites, diabetes, low estimated glomerular filtration rate and high albumin–bilirubin grade were risk factors for serum creatinine elevation after platinum-based transcatheter arterial chemoembolization/transarterial infusion chemotherapy.

Harms of hepatocellular carcinoma surveillance

Purpose of review

Hepatocellular carcinoma (HCC) surveillance in patients with cirrhosis is associated with decreased mortality by enabling early tumor detection. However, the benefits of any cancer screening program must be considered in light of potential physical, financial, and psychological harms, as well as the risk of overdiagnosis. Herein, we summarize the potential harms of HCC surveillance.

Recent findings

To date, two retrospective studies have addressed physical harms of HCC surveillance. Based on these data, 15% to 28% of patients undergoing HCC surveillance experience physical harm including additional cross-sectional imaging or liver biopsy. Although psychological and financial harms have been reported for other cancers, there are currently limited data specific to HCC. An ongoing multi-center prospective study assessing all four types of harms should provide data in near future.

Summary

HCC screening may prevent death by diagnosing tumors at an early stage, but limited sensitivity and specificity of screening tests can result in unintended harms. There is a need for further quality data evaluating both the benefits and harms of HCC surveillance.

Contrast-induced Acute Kidney Injury in Patients with Liver Cirrhosis: A Retrospective Analysis

Contrast-induced acute kidney injury (CI-AKI) has been studied less extensively in patients with liver cirrhosis (LC). It is unclear whether the presence of severe liver disease is actually a predisposing factor for CI-AKI. Liver cirrhosis is extremely common in Pakistan and is attributed to the high prevalence of chronic viral hepatitis. Patients with LC often undergo contrast-enhanced computed tomograms (CECT) for various diagnostic and therapeutic purposes, and there have been concerns regarding them being at risk for CI-AKI. The available literature on this topic is scanty, and no study has been conducted in Pakistan. The purpose of this study, therefore, was to determine the frequency of CI-AKI in patients with LC undergoing CECT and to determine any significant predispositions. We retrospectively analyzed the records of 470 LC patients at our center. The frequency of CI-AKI in our study was 5.1%. A higher mean model for end-stage liver disease (MELD), MELD including sodium (MELD-Na), and Child-Pugh (CP) scores was significantly associated with developing CI-AKI (p<0.05). Patients with CI-AKI also had a significantly higher mean international normalized ratio (INR) and serum bilirubin levels, with lower mean venous bicarbonate and serum sodium levels (p<0.05). Our results show that patients with a more advanced liver disease and poorer synthetic function are increasingly susceptible to developing CI-AKI. Further studies can investigate the role of bicarbonate therapy in preventing CI-AKI in LC.

Acute kidney injury in cirrhotic patients undergoing contrast-enhanced computed tomography

Contrast medium administration is one of the leading causes of acute kidney injury (AKI) in different clinical settings. The aim of the study was to investigate occurrence and predisposing factors of AKI in cirrhotic patients undergoing contrast-enhanced computed tomography (CECT).Datasets of 1279 consecutively hospitalized cirrhotic patients were retrospectively analyzed. Two hundred forty-nine of 1279 patients (mean age 64 ± 11 years, 165 male) who had undergone CECT were selected on the basis of the availability of serum creatinine (sCr) values evaluated before and after CECT (CECT group). In analogy, 203/1279 cases (mean age 66 ± 10 years, 132 male) who had not undergone CECT and had been tested twice for sCr in 7 days were also included as controls (Control group). AKI network criteria were employed to assess contrast-induced AKI (CI-AKI) development. Apart from lack of narrowed double sCr measurements, additional exclusion criteria were active bacterial infections, nephrotoxic drugs intake, and estimated glomerular filtration rate <30 mL/min.AKI developed in 22/249 (8.8%) and in 6/203 (3%) of the CECT and the Control groups, respectively (P = 0.01). The multivariate logistic regression analysis showed that AKI was significantly associated with contrast medium administration (odds ratio [OR]: 3.242, 95% confidence interval [CI]: 1.255-8.375; P = 0.015), female sex (OR: 0.339, 95% CI: 0.139-0.827; P = 0.017), and sCr values (OR: 0.124, 95% CI: 0.016-0.975; P = 0.047). In the CECT group, presence of ascites (OR: 2.796, 95% CI: 1.109-7.052; P = 0.029), female sex (OR: 0.192, 95% CI: 0.073-0.510; P = 0.001), and hyperazotemia (OR: 1.018, 95% CI: 1.001-1.037; P = 0.043) correlated with CI-AKI development at multivariate analysis.CI-AKI is a quite frequent occurrence in cirrhotic patients with female sex, presence of ascites, and hyperazotemia being the predisposing factors.

Renal safety of intravenous gadolinium-enhanced magnetic resonance imaging in patients awaiting liver transplantation

Renal dysfunction in cirrhosis carries a high morbidity and mortality. Given the potential risk of contrast-induced nephropathy associated with iodinated intravenous contrast used in computed tomography (CT), alternate contrast modalities for abdominal imaging in liver transplant candidates need to be examined. The purpose of this study was to examine the renal safety of magnetic resonance imaging (MRI) with gadolinium in patients awaiting liver transplantation. The study involved a retrospective analysis of 352 patients of abdominal MRI with low-dose gadobenate dimeglumine (MultiHance) (0.05 mmol/kg) in patients with cirrhosis and without renal replacement therapy at a single center during the period from 2007 to 2013. For each case, serum creatinine before and within a few days after the MRI were compared. In addition, the patients were analyzed for the development of nephrogenic systemic fibrosis (NSF), a reported complication of gadolinium in chronic kidney disease. The pre-MRI serum creatinine values ranged from 0.36 to 4.86 mg/dL, with 70 patients (20%) having values ≥ 1.5 mg/dL. A comparison of the pre- and post-MRI serum creatinine values did not demonstrate a clinically significant difference (mean change = 0.017 mg/dL; P = 0.38), including those patients with a pre-MRI serum creatinine ≥ 1.5 mg/dL. In addition, no cases of NSF were noted. In conclusion, our findings suggest that MRI with low-dose gadobenate dimeglumine (MultiHance) is a nonnephrotoxic imaging modality in liver transplant candidates, and its use can be cautiously expanded to liver transplant candidates with concomitant renal insufficiency.

Contrast-induced nephropathy in patients with active cancer undergoing contrast-enhanced computed tomography

PURPOSE

This study was performed to measure the incidence and identify potential predictors of contrast-induced nephropathy (CIN) in cancer patients without chronic kidney disease and with normal or near-normal baseline serum creatinine measures who underwent contrast-enhanced computed tomography (CECT). Severity of CIN was reported based on the RIFLE (risk, injury, failure, loss of kidney function, and end-stage renal disease) classification of acute kidney injury.

METHODS

A retrospective analysis was performed on 820 cancer patients who presented at our emergency department from October 2014 to March 2015. CIN was defined as an increase in creatinine concentration of ≥0.5 mg/dL or ≥25 % above baseline that occurred 48 to 72 h after CECT.

RESULTS

The incidence of CIN was 8.0%. Serial CT examination [odds ratio (OR) 4.09; 95% confidence interval (CI) 1.34-12.56], hypotension before the CT scan (OR 3.95; 95% CI 1.77-8.83), liver cirrhosis (OR 2.82; 95% CI 1.06-7.55), BUN/creatinine >20 (OR 2.54; 95% CI 1.44-4.46), and peritoneal carcinomatosis (OR 1.75; 95% CI 1.01-3.00) were independently associated with CIN. Of 66 CIN patients, 44 met any of the severity criteria of the RIFLE classification. Five of these patients died during hospitalization but only one death was related to renal failure.

CONCLUSIONS

Even when the baseline serum creatinine is ≤1.5 mg/dL, a significant portion of cancer patients are still at risk of CIN. Consecutive CECT examinations, hypotension before CT, liver cirrhosis, dehydration, and peritoneal carcinomatosis seem to predispose patients to CIN.

Treatment and management of ascites and hepatorenal syndrome: an update

Ascites and renal dysfunction are frequent complications experienced by patients with cirrhosis of the liver. Ascites is the pathologic accumulation of fluid in the peritoneal cavity, and is one of the cardinal signs of portal hypertension. The diagnostic evaluation of ascites involves assessment of its granulocyte count and protein concentration to exclude complications such as infection or malignoma and to allow risk stratification for the development of spontaneous peritonitis. Although sodium restriction and diuretics remain the cornerstone of the management of ascites, many patients require additional therapy when they become refractory to this treatment. In this situation, the treatment of choice is repeated large-volume paracentesis. Alteration in splanchnic hemodynamics is one of the most important changes underlying the development of ascites. Further splanchnic dilation leads to changes in systemic hemodynamics, activating vasopressor agents and leading to decreased renal perfusion. Small alterations in renal function influence the prognosis, which depends on the cause of renal failure. Prerenal failure is evident in about 70% of patients, whereas in about 30% of patients the cause is hepatorenal syndrome (HRS), which is associated with a worse prognosis. Therefore, effective therapy is of great clinical importance. Recent data indicate that use of the new definition of acute kidney injury facilitates the identification and treatment of patients with renal insufficiency more rapidly than use of the current criteria for HRS. In this review article, we evaluate approaches to the management of patients with ascites and HRS.

Renal dysfunction in end-stage liver disease and post-liver transplant

Renal dysfunction is a frequent complication in patients with end-stage liver disease awaiting orthotopic liver transplantation and in the post-liver transplant period. Although the stereotypical form of renal dysfunction is the hepatorenal syndrome, other causes of acute kidney injury in this population include prerenal azotemia and acute tubular necrosis. Renal injury in a patient with cirrhosis is associated with a poor prognosis.

Implantable continuous Doppler monitoring device for detection of hepatic artery thrombosis after liver transplantation

BACKGROUND

Early hepatic artery thrombosis (eHAT) after liver transplantation occurs in 3% of adults and 8% of children and often results in retransplantation. eHAT is initially asymptomatic and arterial patency is monitored with percutaneous Doppler ultrasound screening (pDUS). The aim of the study is to analyze the diagnostic accuracy of "continuous" Doppler registration (CONDOR) using an implantable miniature Doppler.

METHODS

This prospective observational study was conducted in 102 liver transplant recipients. Hepatic arterial signal is checked by CONDOR at least six times per day for the first 10 days after transplantation with comparison of diagnostic accuracy of CONDOR versus pDUS.

RESULTS

Extra investigations were performed after 48 (11%) regular pDUS where arterial patency was questioned: 32 extra pDUS, 14 computed tomography (CT) angiographies, and 2 reoperations. CT scan confirmed eHAT in 4 cases. In 10 cases of pDUS-suspected eHAT, where subsequent CT showed an open artery, the CONDOR signal was clearly pulsatile. In 2 of 4 patients with five eHATs, a weak arterial signal was inadvertently interpreted as an open artery (sensitivity of 60%). The accuracy for detection of eHAT increased from 93% (pDUS) to 99% (CONDOR). Using CONDOR, additional CT angiographies may be prevented in 10% of cases.

CONCLUSION

CONDOR is a useful adjunct to pDUS because it reduces the false-positive rate of pDUS. Further development of the technique and analysis of the signal generated by CONDOR are needed to improve the sensitivity before CONDOR can replace pDUS as a reliable screening method for detection of eHAT.

Risk factors for radiocontrast nephropathy after emergency department contrast-enhanced computerized tomography

OBJECTIVES

Radiocontrast nephropathy (RCN) is a known complication of procedures in which intravascular iodinated contrast material is used. The authors sought to determine the risk factors for RCN after emergency department (ED) contrast-enhanced computerized tomography (CECT).

METHODS

This was a retrospective case-control study of patients presenting to a tertiary care ED between January 1, 2004, and December 31, 2006. Inclusion criteria were CECT performed in the ED, serum creatinine measured prior to CECT, and serum creatinine measured 48 to 96 hours after CECT. Exclusion criterion was dialysis-dependent renal failure prior to CECT. The outcome of RCN was defined as an absolute creatinine increase of greater than or equal to 0.5 mg/dL, or a 25% increase above baseline. The charts of all RCN patients and a random sample of non-RCN patients were reviewed to document the presence or absence of potential risk factors. Univariate analysis was performed using chi-square and multiple logistic regression applying a weighted technique to account for sampling of non-RCN patients.

RESULTS

Among the 5,006 patients meeting inclusion criteria, 349 (7%) developed RCN. Multiple regression analysis demonstrated that serum creatinine > 2 mg/dL, liver disease, heart failure, hematocrit < 30%, hypertension, and diabetes were risk factors for RCN, whereas age > 75 years, vascular disease, and serum creatinine > 1.5 mg/dL were not. The area under the curve (AUC) for the model was 0.65. Although the risk of RCN increased with the number of risk factors present, we could not develop a model with sufficient diagnostic accuracy to guide clinical decision-making.

CONCLUSIONS

The authors report risk factors for RCN in a large case-control study, but could not develop an accurate decision tool to identify patients at increased risk for RCN after ED CECT.

Surgery in a patient with liver disease

Surgery is often needed in patients with concurrent liver disease. The multiple physiological roles of the liver places these patients at an increased risk of morbidity and mortality. Diseases necessitating surgery like gallstones and hernia are more common in patients with cirrhosis. Assessment of severity of liver dysfunction before surgery is important and the risk benefit of the procedure needs to be carefully assessed. The disease severity may vary from mild transaminase rise to decompensated cirrhosis. Surgery should be avoided if possible in the emergency setting, in the setting of acute and alcoholic hepatitis, in a patient of cirrhosis who is child class C or has a MELD score more than 15 or any patient with significant extrahepatic organ dysfunction. In this subset of patients, all possible means to manage these patients conservatively should be attempted. Modified Child-Pugh scores and model for end-stage liver disease (MELD) scores can predict mortality after surgery fairly reliably including nonhepatic abdominal surgery. Pre-operative optimization would include control of ascites, correction of electrolyte imbalance, improving renal dysfunction, cardiorespiratory assessment, and correction of coagulation. Tests of global hemostasis like thromboelastography and thrombin generation time may be more predictive of the risk of bleeding compared with the conventional tests of coagulation in patients with cirrhosis. Correction of international normalized ratio with fresh frozen plasma does not necessarily mean reduction of bleeding risk and may increase the risk of volume overload and lung injury. International normalized ratio liver may better reflect the coagulation status. Recombinant factor VIIa in patients with cirrhosis needing surgery needs further study. Intra-operatively, safe anesthetic agents like isoflurane and propofol with avoidance of hypotension are advised. In general, nonsteroidal anti-inflammatory drug (NSAIDs) and benzodiazepines should not be used. Intra-abdominal surgery in a patient with cirrhosis becomes more challenging in the presence of ascites, portal hypertension, and hepatomegaly. Uncontrolled hemorrhage due to coagulopathy and portal hypertension, sepsis, renal dysfunction, and worsening of liver failure contribute to the morbidity and mortality in these patients. Steps to reduce ascitic leaks and infections need to be taken. Any patient with cirrhosis undergoing major surgery should be referred to a specialist center with experience in managing liver disease.

Intravenous albumin for the prevention of contrast-induced nephropathy in patients with liver cirrhosis and chronic kidney disease undergoing contrast-enhanced CT

BACKGROUND

The purpose of this study was to evaluate the incidence of contrast-induced nephropathy (CIN), and the effect of intravenous albumin for prophylaxis of CIN in patients with liver cirrhosis (LC) and chronic kidney disease (CKD).

METHODS

We conducted a retrospective study of 81 subjects with LC and CKD (estimated glomerular filtration rate (eGFR)<60 mL/min/1.73 m(2)) who underwent contrast-enhanced computed tomography (CT). Patients received either isotonic sodium bicarbonate solution (3 mL/kg for 1 h before CT and 1 mL/kg/h for 6 h after CT) or albumin (20% albumin, 25 mL for 1 h before CT and 75 mL for 6 h after CT). CIN was defined as an increase of ≥25% or ≥0.5 mg/dL in serum creatinine level.

RESULTS

Overall, CIN developed in three patients (3.7%). Of the 81 subjects, 43 received sodium bicarbonate solution and 38 received albumin. Both groups were comparable with regard to age, sex, diabetes mellitus, and baseline eGFR. The albumin group showed a significantly poorer liver function profile. CIN incidence did not differ significantly between the groups: it occurred in one (2.3%) of the 43 subjects receiving sodium bicarbonate and two (5.3%) of the 38 subjects receiving albumin (P=0.6). However, the albumin group showed a significantly smaller increase in body weight (P=0.03).

CONCLUSION

The incidence of CIN in patients with LC and CKD undergoing contrast-enhanced CT after preventive measures was relatively low. The incidence of CIN was not significantly different between sodium bicarbonate and albumin groups.

Meta-analysis: serum creatinine changes following contrast enhanced CT imaging

PURPOSE

Contrast induced nephropathy (CIN) is defined as a decrease in renal function following administration of contrast media. The aim of this meta-analysis was to asses the overall risk of CIN, chronic loss of kidney function and the need for renal replacement therapy (RRT) after intravenous contrast enhanced CT-scan. Secondly, we aimed to identify subgroups at increased risk for CIN.

MATERIALS AND METHODS

A literature search in Pubmed, Medline, Embase and Cochrane databases was performed. Data extraction was carried out independently by two reviewers. Meta-analysis and meta-regression were performed using an exact likelihood approach.

RESULTS

Forty studies evaluating the incidence of CIN after CT were included. The pooled incidence of CIN was 6.4% (95% CI 5.0-8.1). The risk of RRT after CIN was low, 0.06% (95% CI 0.01-0.4). The decline in renal function persisted in 1.1% of patients (95% CI 0.6-2.1%). Patients with chronic kidney disease (odds ratio 2.26, p<0.001) or diabetes mellitus (odds ratio 3.10, p<0.001) were at increased risk for the development of CIN.

CONCLUSION

CIN occurred in 6% of patients after contrast enhanced CT. In 1% of all patients undergoing contrast enhanced CT the decline in renal function persisted.

Management of renal dysfunction in patients receiving a liver transplant

Renal dysfunction is a frequent complication in patients with endstage liver disease awaiting orthotopic liver transplantation. Although the stereotypical form of renal dysfunction is the hepatorenal syndrome, common causes of acute kidney injury include prerenal azotemia and acute tubular necrosis in this population. Management involves hemodynamic support, renal replacement therapy, and mitigation of risk factors. Renal dysfunction in a cirrhotic patient usually implies a poor prognosis in the absence of liver transplantation. An important issue is the frequent need for kidney, in addition to liver, transplantation if renal insufficiency has been persistent in a decompensated cirrhotic.

Baseline incidence and severity of renal insufficiency evaluated by estimated glomerular filtration rates in patients scheduled for contrast-enhanced CT

BACKGROUND

Although pre-existing renal insufficiency (RI) is the most important risk factor for contrast-induced nephropathy (CIN), the background distribution of baseline renal function has not been investigated thoroughly in patients scheduled for contrast-enhanced CT.

PURPOSE

To investigate the incidence and severity of baseline RI evaluated by estimated glomerular filtration rates (eGFR) in patients who underwent contrast-enhanced CT at an academic center.

MATERIAL AND METHODS

A total of 6586 patients (3630 men and 2956 women; mean age 57.0 ± 11.9 years) who underwent contrast-enhanced CT between January and December 2008 were retrospectively studied. Of these, 829 had cardiovascular diseases (CVD), 5116 had oncologic diseases, 178 had diabetes mellitus (DM), and 1572 had chronic liver disease (CLD). The eGFR (mL/min/1.73 m(2)) was calculated from their serum creatinine level. Mild, moderate-a, moderate-b, and severe RI were recorded at 60 < =eGFR < 90, 45 < =eGFR < 60, 30 < =eGFR < 45 and eGFR < 30, respectively.

RESULTS

Of the 6586 patients, 1.6%, 3.7%, 13.7%, and 54.2% were judged to present with severe, moderate-b, moderate-a, and mild RI, respectively. While moderate-b-to-severe RI was recorded in 133 (3.2%) of 4161 patients aged 70 years or less, it was observed in 218 (9.0%) of the 2425 patients who were 71 years or older. Among the 829 CVD patients, 9.9% manifested moderate-b-to-severe- and 73.0% mild-to-moderate-a RI. The corresponding rates were 4.4% and 68.9% for oncologic disease, 16.9% and 61.2% for DM, and 4.8% and 71.5% for CLD patients. By univariate analysis, there was a significant association between moderate-b-to-severe RI and the advanced age, CVD, DM, and non-oncologic disease. Multivariate analysis showed that the advanced age, DM, and non-oncologic disease were statistically associated with moderate-b-to-severe RI.

CONCLUSION

The incidence of RI of eGFR < 45mL/min/1.73 m(2) at baseline was high in patients with advanced age, CVD and DM and in patients without oncologic disease.

The management of hospitalized patients with cirrhosis: the Mount Sinai experience and a guide for hospitalists

BACKGROUND

Cirrhosis and chronic liver disease carry appreciable morbidity and mortality. Cirrhotic patients frequently require hospitalization and their care is both extremely complex and labor-intensive.

AIM

We seek to provide a review for gastroenterologists, hepatologists, internists, and hospitalists on the approach to care in patients hospitalized for complications related to end-stage liver disease.

METHODS

The Mount Sinai Medical Center's inpatient liver service has developed an integrated team approach for cirrhotic patients and throughout the years has educated fellows-in-training and medical house staff on both the treatment principles and "pearls" in managing the hospitalized cirrhotic patient. We reviewed the literature and provide recommendations on the management of complications of end-stage liver disease. Additionally, we provide a review of the protocols used at our institution in the care for cirrhotic patients.

RESULTS

Major complications of advanced liver disease include infection, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, portal hypertension, variceal hemorrhage, hepatorenal syndrome, and hepatocellular carcinoma. Management of these complications involves selecting the appropriate diagnostic studies and prompt administration of therapy.

CONCLUSIONS

There are many complications of cirrhosis. Management of these complications can be complex and are targeted at stabilizing the patient's clinical condition. Liver transplantation remains the only definitive treatment.

Creatinine increases after intravenous contrast administration: incidence and impact

OBJECTIVE

The incidence of creatinine increases after intravenous contrast (postcontrast creatinine increases, PCCI) is controversial, ranging from 0% to >25%. We sought to determine what factors influenced these divergent estimates of PCCI incidence. Where possible, the association of PCCI with long-term adverse outcomes was also studied.

MATERIALS AND METHODS

Both observational studies and prospective randomized trials were reviewed. Definitions of clinically significant PCCI, incidence of PCCI, and its association with baseline kidney function, the setting in which intravenous contrast was administered, and the short- and long-term consequences of PCCI were extracted.

RESULTS

Baseline renal function impairment and inpatient versus outpatient status are the major risk factors for PCCI. PCCI is possibly associated with clinically significant short- and long-term adverse events.

CONCLUSIONS

PCCI occurs despite a number of potential confounding issues. The incidence is increased as kidney function at baseline is diminished and for inpatients. There is limited data on long-term outcomes following PCCI in this setting.

Renal failure in patients with hepatocellular carcinoma and ascites undergoing transarterial chemoembolization

BACKGROUND

Ascites is often present in patients with hepatocellular carcinoma (HCC) with cirrhosis. Advanced cirrhosis may predispose to renal dysfunction. Acute renal failure (ARF) may occur after transarterial chemoembolization (TACE) for HCC because of radiocontrast agents. This study aimed to investigate the incidence and risk factors of ARF and prognostic predictors in HCC patients with ascites undergoing TACE.

METHODS

A total of 591 HCC patients receiving TACE were enrolled.

RESULTS

In a mean follow-up duration of 19+/-17 months, 239 (40.4%) patients undergoing TACE died. Ascites, which was present in 91 (15.4%) patients at entry, independently predicted a poor prognosis in the Cox proportional hazard model [risk ratio (RR): 1.71, P=0.002]. Of these, 11 (12.6%) of 87 patients with complete follow-up developed ARF after TACE. Serum albumin level <3.3 g/dl (odds ratio: 7.3, P=0.009) was the only independent risk factor associated with ARF in the logistic regression analysis. ARF (RR: 2.17, P=0.036), alpha-fetoprotein >400 ng/ml (RR: 1.84, P=0.04), multiple tumours (RR: 2.11, P=0.013), tumour size > or = 5 cm (RR: 2.32, P=0.006) and serum sodium level <139 mmol/L (RR: 2.4, P=0.005) were independent poor prognostic predictors for HCC patients with ascites receiving TACE.

CONCLUSIONS

Pre-existing ascites is associated with increased mortality in HCC patients receiving TACE. In HCC patients with ascites, hypoalbuminaemia is associated with the occurrence of post-TACE ARF. Post-TACE ARF is a poor prognostic predictor in this subset of HCC patients.