Prognosis of Acute Kidney Injury and Hepatorenal Syndrome in Patients with Cirrhosis: A Prospective Cohort Study.

Andrew S Allegretti,Raymond T Chung,Hector Tamez,S Ananth Karumanchi,Julia Wenger,Joshua Wibecan,Ravi I Thadhani,Sahir Kalim,Guillermo Ortiz,Joseph J Deferio

doi:10.1155/2015/108139

Abstract

Background/Aims. Acute kidney injury is a common problem for patients with cirrhosis and is associated with poor survival. We aimed to examine the association between type of acute kidney injury and 90-day mortality. Methods. Prospective cohort study at a major US liver transplant center. A nephrologist's review of the urinary sediment was used in conjunction with the 2007 Ascites Club Criteria to stratify acute kidney injury into four groups: prerenal azotemia, hepatorenal syndrome, acute tubular necrosis, or other. Results. 120 participants with cirrhosis and acute kidney injury were analyzed. Ninety-day mortality was 14/40 (35%) with prerenal azotemia, 20/35 (57%) with hepatorenal syndrome, 21/36 (58%) with acute tubular necrosis, and 1/9 (11%) with other (p = 0.04 overall). Mortality was the same in hepatorenal syndrome compared to acute tubular necrosis (p = 0.99). Mortality was lower in prerenal azotemia compared to hepatorenal syndrome (p = 0.05) and acute tubular necrosis (p = 0.04). Ten participants (22%) were reclassified from hepatorenal syndrome to acute tubular necrosis because of granular casts on urinary sediment. Conclusions. Hepatorenal syndrome and acute tubular necrosis result in similar 90-day mortality. Review of urinary sediment may add important diagnostic information to this population. Multicenter studies are needed to validate these findings and better guide management.

Highlights

Acute kidney injury (AKI) is a common and life-threatening problem for patients with cirrhosis [1,2,3]
prerenal azotemia (PRA) acute tubular necrosis (ATN) Other had evidence of parenchymal renal disease (56%) or exposure to nephrotoxic drugs (22%). Among those with cirrhosis and AKI, 90-day mortality is the same between those with hepatorenal syndrome (HRS) and ATN in crude analysis and after adjusting for age and a cirrhosis-specific prognostic assessment (MELD or CLIFSOFA score)
Because infection can be a trigger of PRA, HRS [25, 28], and ATN [29], we elected to include those with infection within a PRA/HRS/ATN scheme

Summary

Introduction

Acute kidney injury (AKI) is a common and life-threatening problem for patients with cirrhosis [1,2,3]. The most common etiologies are prerenal azotemia (PRA), acute tubular necrosis (ATN), and hepatorenal syndrome (HRS), but other causes such as glomerulonephritis, medication toxicity, and abdominal compartment syndrome from tense ascites occur as well [3, 4]. Regardless of etiology, AKI is associated with reduced survival [5,6,7]. Hepatorenal syndrome is thought to be due to splanchnic vasodilation causing hormonal imbalances that result in renal vasoconstriction and impaired renal function [4, 11]. Several studies suggest that HRS is associated with the highest mortality of all types of AKI [12,13,14]. A diagnosis of HRS-related AKI is felt to have greater clinical significance over other types of AKI. There is no definitive test for HRS, which remains a challenging diagnosis for clinicians

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Conclusion