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AKI persistence at 48 h predicts mortality in patients with acute on chronic liver failure

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Abstract

Background and aim

Management of acute kidney injury (AKI) in cirrhotics has undergone a paradigm change. We evaluated the impact of AKI persistence at 48 h on outcome in patients with acute on chronic liver failure (ACLF).

Methods

Consecutive patients with ACLF (n = 373) were prospectively followed. AKI was defined as increase in serum creatinine of 0.3 mg/dl or 1.5- to 2-fold from baseline. Persistent AKI was defined as nonresponsive AKI at 48 h with respect to admission serum creatinine.

Results

AKI at admission was present in 177 (47.5 %) patients. At 48 h, 73 % patients had persistent AKI and 27 % had responsive AKI. High Model for End-Stage Liver Disease (MELD) (≥26) [p, odds ratio (OR), 95 % confidence interval (CI)] [<0.001, 3.65 (2.1–3.67)], systemic inflammatory response syndrome (SIRS) [0.03, 1.6 (1.02–21.6)], and age (≥42 years) [0.03, 1.84 (1.19–2.85)] were significant predictors of AKI persistence. Persistent AKI was associated with significantly higher in-hospital mortality [p < 0.001, hazard ratio (HR) 1.7, 95 % CI 1.32–2.27]. We further found a lower cutoff for serum creatinine of 1.14 mg/dl at 48 h with better sensitivity of 61 %, specificity of 61 %, and likelihood ratio (LR+) of 1.6, correctly classifying 61 %, as against the conventional cutoff of 1.5 mg/dl with sensitivity of 37 %, specificity of 57 %, and LR+ of 3.3, correctly classifying 56 %. This new cutoff also predicted mortality with higher odds (OR 2.4, 95 % CI 1.3–4.8) as compared with the conventional cutoff (OR 2.1, 95 % CI 1.1–4.1).

Conclusion

AKI persistence at 48 h predicts mortality better than serum creatinine of 1.5 mg/dl in patients with ACLF. Serum creatinine value of 1.14 mg/dl and smaller increases in its value should be considered for risk stratification of patients with ACLF for interventional strategies.

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Abbreviations

ACLF:

Acute on chronic liver failure

AKI:

Acute kidney injury

AKIN:

Acute Kidney Injury Network

APASL:

Asian Pacific Association for the Study of the Liver

ATN:

Acute tubular necrosis

AUROC:

Area under the curve of the receiver operating characteristic

C-index:

Concordance index

CI:

Confidence interval

CTP:

Child–Turcotte–Pugh

HCC:

Hepatocellular carcinoma

HE:

Hepatic encephalopathy

HR:

Hazard ratio

HRS:

Hepatorenal syndrome

INR:

International normalized ratio

MAP:

Mean arterial pressure

MELD:

Model for End-Stage Liver Disease

OR:

Odds ratio

RRT:

Renal replacement therapy

SBP:

Spontaneous bacterial peritonitis

SIRS:

Systemic inflammatory response syndrome

WBC:

White blood cell count

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Authors and Affiliations

  1. Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India

    Rakhi Maiwall, Kapil Jamwal & Shiv Kumar Sarin

  2. Department of Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India

    Guresh Kumar, Ankit Bharadwaj, Ajeet Singh Bhadoria & Priyanka Jain

Authors
  1. Rakhi Maiwall
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  2. Guresh Kumar
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  3. Ankit Bharadwaj
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  4. Kapil Jamwal
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  5. Ajeet Singh Bhadoria
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  6. Priyanka Jain
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  7. Shiv Kumar Sarin
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Contributions

The study concept and design were constructed by R.M. and S.K.S.; acquisition of data was carried out by R.M., K.J., P.J., and A.B.; statistical analysis was done by G.K. and A.S.B.; the manuscript was drafted by R.M. and S.K.S., and critically revised for important intellectual content by S.K.S.; administrative and technical support was provided by S.K.S. All authors approved the final draft.

Corresponding author

Correspondence to Shiv Kumar Sarin.

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Conflict of interest

R.M., G.K., A.B., K.J., A.S.B., P.J., and S.K.S. declare that they have no competing interests.

Electronic supplementary material

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Supplementary material 1 (DOCX 13 kb)

12072_2017_9822_MOESM2_ESM.jpg

Suppl Fig. 1 Box plot depicting serum creatinine in patients with no AKI/responsive AKI versus persistent AKI (A) at Admission and (B) at 48 h (JPEG 102 kb)

12072_2017_9822_MOESM3_ESM.jpg

Suppl Fig. 2 Stratification of patients with respect to AKIN stage at admission and serum creatinine cutoff of 1.5 mg/dl for (A) AKI at admission and (B) persistent AKI at 48 h (JPEG 151 kb)

Supplementary material 4 (DOCX 12 kb)

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Maiwall, R., Kumar, G., Bharadwaj, A. et al. AKI persistence at 48 h predicts mortality in patients with acute on chronic liver failure. Hepatol Int 11, 529–539 (2017). https://doi.org/10.1007/s12072-017-9822-1

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  • DOI: https://doi.org/10.1007/s12072-017-9822-1

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