Association of AKI with mortality and complications in hospitalized patients with cirrhosis

Abstract

Acute kidney injury (AKI) is a common and devastating complication in patients with cirrhosis. However, the definitions of AKI employed in studies involving patients with cirrhosis have not been standardized, lack sensitivity, and are often limited to narrow clinical settings. We conducted a multicenter, prospective observational cohort study of patients with cirrhosis and AKI, drawn from multiple hospital wards, utilizing the modern acute kidney injury network (AKIN) definition and assessed the association between AKI severity and progression with in-hospital mortality. Of the 192 patients who were enrolled and included in the study, 85 (44%) progressed to a higher AKIN stage after initially fulfilling AKI criteria. Patients achieved a peak severity of AKIN stage 1, 26%, stage 2, 24%, and stage 3, 49%. The incidence of mortality, general medical events (bacteremia, pneumonia, urinary tract infection), and cirrhosis-specific complications (ascites, encephalopathy, spontaneous bacterial peritonitis) increased with severity of AKI. Progression was significantly more common and peak AKI stage higher in nonsurvivors than survivors (P < 0.0001). After adjusting for baseline renal function, demographics, and critical hospital- and cirrhosis-associated variables, progression of AKI was independently associated with mortality (adjusted odds ratio = 3.8, 95% confidence interval 1.3-11.1).

Conclusion: AKI, as defined by AKIN criteria, in patients with cirrhosis is frequently progressive and severe and is independently associated with mortality in a stage-dependent fashion. Methods for earlier diagnosis of AKI and its progression may result in improved outcomes by facilitating targeted and timely treatment of AKI.

Figure 1. Degree of AKI progression and mortality

Progression is defined by an increase in AKIN stage after initially fulfilling AKIN criteria. Progression to dialysis refers to any patient who presented as non-dialysis dependent but subsequently developed the requirement for dialysis.

Figure 2. Incidence and extend of AKI progression and subsequent mortality by initial AKIN stage

Patients are categorized by their stage upon first meeting AKIN criteria. Progression refers to worsening to a higher AKIN stage, with patients who are initially in stage 3 by creatinine criteria but not requiring dialysis counted as progressing if dialysis was subsequently initiated. * 3 patients were initiated on dialysis on the day of enrollment

Figure 3. Impact of AKI progression versus peak severity on mortality

Patients are categorized by the peak AKIN stage they attained. “Progressors” refers to patients who worsened from their initial stage to achieve this peak while “Non-progressors” were already in their peak stage at the time of first meeting AKIN criteria.