Spectrum and Short-term Outcome of Renal Impairment in Cirrhosis

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Renal failure is the most powerful predictor of death in decompensated cirrhosis. We conducted this prospective, observational, cohort study to determine spectrum of acute kidney injury (AKI) as per (IAC /ADQI , International ascites club/Acute Dialysis Quality initiative) definition in cirrhotics at admission or in hospital stay and study its outcome. Cirrhotic patients diagnosed with AKI, as per (IAC/ADQI) definition, were enrolled and evaluated for the cause and type of AKI as per study definitions, investigated and treated as per study protocol. They were followed up to see reversibility of AKI and its effect on patients in hospital, 1 & 3 month outcome. 395 consecutive cirrhotics with renal impairment enrolled. In hospital mortality 154 (39%). 226 (57.2%) survived at 1 month and 173 (43.8%) at 3 months. Median CTP 10 (5 – 14) and median MELD 25 (6 – 57). RRT (renal replacement therapy) required in 120 (30.4%). Infections were most common in precipitants with SBP, 84 (21.4%) the most common focus. VRAKI (volume responsive AKI) was commonest,198 (50.1%). Among VNRAKI (volume non responsive AKI), HRS (hepatorenal syndrome) seen in 85 (21.5%), ATN (Acute Tubular Necrosis in 55 (13.9%) and 9 (2.3%) had AGN (acute glomerulonephritis). Associated CKD (chronic kidney disease) seen in 48 (12.2%). VRAKI had best outcome followed by AGN and associated CKD. ATN/HRS had poor outcomes. Outcome was significantly poor in ACLF (acute on chronic liver failure), terlipressin non responders and recurrent AKI. On multivariate analysis MELD score, serum albumin, presence of SBP and hypotension with inotropes requirement were significantly associated with HRS/ATN development. Presence of HE, low albumin and ATN/HRS were significantly associated with death. AKI in cirrhotics was associated with significantly high in-hospital mortality, higher need for renal replacement therapy, as well as progressively reduced 1 month and 3 month survival. VRAKI was the most common with best outcome followed by HRS and ATN. Associated CKD had better 1,3 month survival than HRS/ATN. Presence of HRS/ATN, ACLF, recurrence of AKI in the same hospitalization were associated with poor 1 month and 3 month survival. MELD score, SBP, presence of hypotension with inotrope requirement were significant predictors of HRS/ATN development and presence of HRS/ATN, HE, low serum albumin were significant predictors of death. The survival in HRS/ATN did not correlate with infection related parameters whereas that in VRAKI did.