Incidence, Mortality and Predictors of Acute Kidney Injury in Patients with Cirrhosis: A Systematic Review and Meta-analysis

Abstract

Background and Aims: Acute kidney injury (AKI) is common in patients with cirrhosis but the incidence is heterogeneous among studies. We performed a meta-analysis to describe the incidence of AKI and its impact on patient mortality in patients with cirrhosis. We also evaluated the admission variables predicting development of AKI. Methods: A systematic search of various databases was performed up to November 2018. Meta-analyses were performed using random effects models. Results: Of 18,474 patients with cirrhosis from 30 selected studies, 5,648 developed AKI, with a pooled incidence of 29% (95% confidence interval [CI]: 28-30%, I ² of 99%). In-hospital mortality assessed in eight studies was six-fold higher among AKI patients, as compared to those without AKI (odds ratio [OR] 6.72, 95% CI: 3.47-13, p<0.0001, I ² of 70%). Three studies on patients admitted to intensive care showed about six-fold higher mortality among AKI patients (OR 5.90, 95% CI: 3.21-10.85, p>0.0001). Mortality remained significantly high, at days 30 and 90 and even at 1-year follow up after development of AKI. Of 12 admission variables analyzed, model for end-stage liver disease score, Child-Pugh-Turcotte stage C, presence of ascites, and presence of sepsis/septic shock were statistically significant risk factors for AKI. Conclusions: AKI occurred in about 29% of patients with cirrhosis and is associated with a six-fold increased risk of in-hospital mortality. Mortality remained high even in long-term follow-up of 1 year. Patients at risk for AKI development can be recognized at admission. Prospective studies are needed to develop strategies for improving outcome of these patients.

Keywords: Acute kidney injury; Cirrhosis; Mortality; Outcomes.

Fig. 1.. Search strategy for included studies.

Fig. 2.. Forest plot depicting pooled incidence of acute kidney injury in patients with cirrhosis.

Fig. 3.. Forest plots on mortality outcomes comparing cirrhosis patients with acute kidney injury vs. without acute kidney injury for A) overall in-hospital mortality, B) in-hospital mortality for intensive care patients, C) mortality at 30 days follow-up, D) mortality at 90 days follow-up, E) mortality at 1-year follow-up.

Fig. 4.. Forest plots showing admission variables predicting acute kidney injury.

A) Model for end-stage liver disease score, B) Child-Pugh-Turcotte score, C) presence of ascites, and D) presence of sepsis/septic shock. Risk of acute kidney injury is reduced among patients with variceal bleeding (E).