Acute Kidney Injury in Patients With Cirrhosis and Chronic Kidney Disease: Results From the HRS-HARMONY Consortium

Abstract

Background & aims: Chronic kidney disease (CKD) frequency is increasing in patients with cirrhosis and these individuals often experience acute kidney injury (AKI). Direct comparisons of outcomes between AKI-only versus AKI on CKD (AoCKD) among patients with cirrhosis are not well described.

Methods: A total of 2057 patients with cirrhosis and AKI across 11 hospital networks from the HRS-HARMONY consortium were analyzed (70% AKI-only and 30% AoCKD). The primary outcome was unadjusted and adjusted 90-day mortality, with transplant as a competing risk, using Fine and Gray analysis.

Results: Compared with patients with AKI-only, patients with AoCKD had higher median admission creatinine (2.25 [interquartile range, 1.7-3.2] vs 1.83 [1.38-2.58] mg/dL) and peak creatinine (2.79 [2.12-4] vs 2.42 [1.85-3.50] mg/dL) but better liver function parameters (total bilirubin 1.5 [interquartile range, 0.7-3.1] vs 3.4 [1.5-9.3] mg/dL; and international normalized ratio 1.4 [interquartile range, 1.2-1.8] vs 1.7 [1.39-2.2]; P < .001 for all). Patients with AoCKD were more likely to have metabolic dysfunction associated steatotic liver disease cirrhosis (31% vs 17%) and less likely to have alcohol-associated liver disease (26% vs 45%; P < .001 for both). Patients with AKI-only had higher unadjusted mortality (39% vs 30%), rate of intensive care unit admission (52% vs 35%; P < .001 for both), and use of renal-replacement therapy (20% vs 15%; P = .005). After adjusting for age, race, sex, transplant listing status, and Model for End-Stage Liver Disease-Sodium score, AoCKD was associated with a lower 90-day mortality compared with AKI-only (subhazard ratio, 0.72; 95% confidence interval, 0.61-0.87).

Conclusions: In hospitalized patients with AKI and cirrhosis, AoCKD was associated with lower 90-day mortality compared with AKI-only. This may be caused by the impact of worse liver function parameters in the AKI-only group on short-term outcomes. Further study of the complicated interplay between acute and chronic kidney disease in cirrhosis is needed.

Keywords: Acute On Chronic Kidney Disease; Liver Failure; Liver Transplant; Renal Failure.