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. 2022 Dec;42(12):2800-2814.
doi: 10.1111/liv.15413. Epub 2022 Sep 19.

Natural history, spectrum and outcome of stage 3 AKI in patients with acute-on-chronic liver failure

Rakhi Maiwall  1 , Archana Rastogi  2 , Samba Siva R Pasupuleti  3 , Ashini K Hidam  4 , Mansi Singh  4 , Sonia Kadyan  4 , Priyanka Jain  5 , Guresh Kumar  5 , Shiv K Sarin  1
Affiliations

Natural history, spectrum and outcome of stage 3 AKI in patients with acute-on-chronic liver failure

Rakhi Maiwall et al. Liver Int. 2022 Dec.

Abstract

Background and aim: There is limited data on natural course and interventions in stage-3 acute kidney injury (AKI-3) in patients with acute-on-chronic liver failure (ACLF). We studied the factors of AKI-3 reversal and outcomes of dialysis in ACLF patients.

Methods: Consecutive patients with ACLF were prospectively enrolled (n = 1022) and variables determining AKI and its outcomes were analysed.

Results: At 1 month, 337 (33%) patients had AKI-3, of which, 131 had AKI-3 at enrolment and 206 developed AKI-3 during hospital stay. Of patients with AKI-3 at enrolment, 18% showed terlipressin response, 21% had AKI resolution and 59% required dialysis. High MELD (≥35) (model 1), serum bilirubin (≥23 mg/dL) (model 2) and AARC score (≥11) (model 3) were independent risk factors for dialysis. Dialysis was associated with worse survival in all AKI patients but improved outcomes in patients with AKI-3 (p = .022, HR 0.69 [0.50-0.95]). Post-mortem kidney biopsies (n = 61) revealed cholemic nephropathy (CN) in 54%, acute tubular necrosis (ATN) in 31%, and a combination (CN and ATN) in 15%. Serum bilirubin was significantly higher in patients with CN, CN and ATN compared with ATN respectively ([30.8 ± 12.2] vs. [26.7 ± 12.0] vs. [18.5 ± 9.8]; p = .002).

Conclusion: AKI-3 rapidly increases from 13% to 33% within 30 days in ACLF patients. Histopathological data suggested cholemic nephropathy as the predominant cause which correlated with high bilirubin levels. AKI-3 resolves in only one in five patients. Patients with AARC grade 3 and MELD >35 demand need for early dialysis in AKI-3 for improved outcomes.

Keywords: Bile cast; CRRT; RRT; SLED; cholemic nephropathy; dialysis; sepsis.

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References

REFERENCES

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