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. 2025 Nov;23(12):2232-2241.e10.
doi: 10.1016/j.cgh.2025.03.015. Epub 2025 May 10.

Ambulatory Acute Kidney Injury in Patients With Cirrhosis Is Common and Burdensome

Kavish R Patidar  1 , Ruben Hernaez  2 , Yan Liu  2 , George Cholankeril  3 , Jennifer R Kramer  2 , Thom Taylor  2 , Prasun Jalal  3 , Tzu-Hao Lee  3 , Avegail G Flores  4 , Giuseppe Cullaro  5 , Andrew S Allegretti  6 , Pere Gines  7 , Fasiha Kanwal  2
Affiliations

Ambulatory Acute Kidney Injury in Patients With Cirrhosis Is Common and Burdensome

Kavish R Patidar et al. Clin Gastroenterol Hepatol. 2025 Nov.

Abstract

Background & aims: Little is known about ambulatory acute kidney injury (A-AKI), which develops in an outpatient setting.

Methods: We conducted a retrospective cohort study of patients diagnosed with cirrhosis between January 1, 2018, and December 31, 2019 from 130 hospitals in the Veterans Affairs healthcare system. Patients were classified as having incident A-AKI if they met the International Club of Ascites AKI criteria in an outpatient setting. We used multivariable regression models to identify factors associated with A-AKI development within 1 year of cirrhosis diagnosis. We also conducted a structured implicit review of patients' medical charts to determine the precipitants of A-AKI. We examined the rates of AKI-resolution, hemodialysis and death at 90 days.

Results: Among 55,880 patients with cirrhosis [median age 66 years, 38% alcohol-related cirrhosis (alcohol-associated liver disease), median Model for End-Stage Liver Disease-Sodium 10, 34% ascites] followed for a median of 3.4 years, 6889 (12%) patients developed incident A-AKI. Patients with ascites (odds ratio [OR], 2.51), Model for End-Stage Liver Disease-Sodium >15 (OR, 1.58), hepatocellular carcinoma (OR, 1.45) or alcohol-associated liver disease (OR, 1.37) had higher odds of developing A-AKI. In total, 60% had AKI-resolution, 4.5% progressed to hemodialysis, and 12% died within 90 days of A-AKI onset. In a review of medical records of 250 randomly selected patients with A-AKI, key precipitants were hypovolemia due to diuretics and gastrointestinal losses, and nephrotoxin medication exposure. Overall, 42% of A-AKI events were unrecognized.

Conclusions: A-AKI is common in cirrhosis, associated with high 90-day mortality, and significantly under-recognized. Targeted interventions for early diagnosis and treatment could improve outcomes in high-risk patients.

Keywords: Ascites; Chronic Kidney Disease; Hepatorenal Syndrome; Portal Hypertension; Renal Failure.

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