The Role of Peritoneal Dialysis in the Treatment of Acute Kidney Injury in Patients With Acute-on-Chronic Liver Failure: A Prospective Brazilian Study.

Welder Zamoner,André Luís Balbi,Daniela Ponce,Erica Pires da Rocha,Dayana Bitencourt Dias,Christiane Kojima

doi:10.3389/fmed.2021.713160

Welder Zamoner, André Luís Balbi + Show 4 more

Open Access

https://doi.org/10.3389/fmed.2021.713160

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Abstract

This study aimed to explore the role of peritoneal dialysis (PD) in acute-on-chronic liver disease (ACLD) in relation to metabolic and fluid control and outcome. Fifty-three patients were treated by PD (prescribed Kt/V = 0.40/session), with a flexible catheter, tidal modality, using a cycler and lactate as a buffer. The mean age was 64.8 ± 13.4 years, model of end stage liver disease (MELD) was 31 ± 6, 58.5% were in the intensive care unit, 58.5% needed intravenous inotropic agents including terlipressin, 69.5% were on mechanical ventilation, alcoholic liver disease was the main cause of cirrhosis and the main dialysis indications were uremia and hypervolemia. Blood urea and creatinine levels stabilized after four sessions at around 50 and 2.5 mg/dL, respectively. Negative fluid balance (FB) and ultrafiltration (UF) increased progressively and stabilized around 3.0 L and −2.7 L/day, respectively. Weekly-delivered Kt/V was 2.7 ± 0.37, and 71.7% of patients died. Five factors met the criteria for inclusion in the multivariable analysis. Logistic regression identified as risk factors associated with Acute Kidney Injury (AKI) in ACLD patients: MELD (OR = 1.14, CI 95% = 1.09–2.16, p = 0.001), nephrotoxic AKI (OR = 0.79, CI 95% = 0.61–0.93, p = 0.02), mechanical ventilation (OR = 1.49, CI 95% = 1.14–2.97, p < 0.001), and positive fluid balance (FB) after two PD sessions (OR = 1.08, CI 95% = 1.03–1.91, p = 0.007). These factors were significantly associated with death. In conclusion, our study suggests that careful prescription may contribute to providing adequate treatment for most Acute-on-Chronic Liver Failure (ACLF) patients without contraindications for PD use, allowing adequate metabolic and fluid control, with no increase in the number of infectious or mechanical complications. MELD, mechanical complications and FB were factors associated with mortality, while nephrotoxic AKI was a protective factor. Further studies are needed to better investigate the role of PD in ACLF patients with AKI.

Highlights

Acute kidney injury (AKI) is a common complication of acuteon-chronic liver failure (ACLF), occurring in up to 20% of hospitalized cirrhotic patients [1]
Patients who were hospitalized with ACLF as the primary diagnosis and had ischemic or nephrotoxic stage 3 AKI according to the KDIGO criteria were eligible for enrolment [14]
During the study period (8 years), a total of 132 ACLF patients were treated by dialysis: 53 by peritoneal dialysis (PD) (40.1%) and 79 by HD (59.9%), of which 35 were treated by conventional and 44 by prolonged HD

Summary

Introduction

Acute kidney injury (AKI) is a common complication of acuteon-chronic liver failure (ACLF), occurring in up to 20% of hospitalized cirrhotic patients [1]. The main reasons for the development of AKI in patients with decompensated cirrhosis are infections, hypovolemia associated with bleeding or the use of diuretics, nephrotoxicity (drug-induced or contrast-induced nephropathy), hepatorenal syndrome (HRS), and parenchymal nephropathy [2,3,4]. This study demonstrated that the most frequent cause of AKI among cirrhotic patients was bacterial infection (46%), followed by volume depletion (32%), HRS (13%), and parenchymal nephropathy (9%). The 90-day mortality was high (60%), but it was high among patients with AKI associated with infections or HRS [2] and among patients that needed kidney replacement therapy (KRT), reaching 80% [2,3,4,5]

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