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

Shelsea A St Hillien; Jevon E Robinson; Tianqi Ouyang; Kavish R Patidar; Justin M Belcher; Giuseppe Cullaro; Kevin R Regner; Raymond T Chung; Nneka Ufere; Juan Carlos Q Velez; Javier A Neyra; Sumeet K Asrani; Hani Wadei; J Pedro Teixeira; Danielle L Saly; Josh Levitsky; Eric Orman; Deirdre Sawinski; Leigh Anne Dageforde; Andrew S Allegretti; HRS-HARMONY Consortium

doi:10.1016/j.cgh.2024.10.023

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

Clin Gastroenterol Hepatol. 2024 Dec 13:S1542-3565(24)01074-7. doi: 10.1016/j.cgh.2024.10.023. Online ahead of print.

Authors

Shelsea A St Hillien¹, Jevon E Robinson¹, Tianqi Ouyang¹, Kavish R Patidar², Justin M Belcher³, Giuseppe Cullaro⁴, Kevin R Regner⁵, Raymond T Chung⁶, Nneka Ufere⁶, Juan Carlos Q Velez⁷, Javier A Neyra⁸, Sumeet K Asrani⁹, Hani Wadei¹⁰, J Pedro Teixeira¹¹, Danielle L Saly¹, Josh Levitsky¹², Eric Orman¹³, Deirdre Sawinski¹⁴, Leigh Anne Dageforde¹⁵, Andrew S Allegretti¹⁶; HRS-HARMONY Consortium

Affiliations

¹ Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
² Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
³ Section of Nephrology, Department of Internal Medicine, Yale University and VA Connecticut Healthcare, New Haven, CT, USA.
⁴ Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
⁵ Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI, USA.
⁶ Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
⁷ Department of Nephrology, Ochsner Health, New Orleans, LA, USA; Ochsner Clinical School, The University of Queensland, Brisbane, Australia.
⁸ Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
⁹ Baylor University Medical Center, Dallas, TX, USA.
¹⁰ Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA.
¹¹ Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA.
¹² Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
¹³ Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA.
¹⁴ Weil Cornell Medical College, New York, New York.
¹⁵ Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Boston, MA.
¹⁶ Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA. Electronic address: [email protected].

PMID: 39675402
DOI: 10.1016/j.cgh.2024.10.023

Abstract

Background: 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 vs. AKI on CKD (AoCKD) among patients with cirrhosis are not well described.

Methods: 2,057 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 to patients with AKI-only, patients with AoCKD had higher median admission creatinine (2.25 [IQR 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 [IQR 0.7, 3.1] vs. 3.4 [1.5, 9.3] mg/dL; and INR 1.4 [IQR 1.2, 1.8] vs. 1.7 [1.39, 2.2]; p<0.001 for all). Patients with AoCKD were more likely to have metabolic dysfunction associated steatotic liver disease (MASLD) cirrhosis (31% vs. 17%) and less likely to have alcohol-associated liver disease (26% vs. 45%; p<0.001 for both). Patients with AKI-only had higher unadjusted mortality (39% vs. 30%), rate of intensive care unit admission (52% vs. 35%; p<0.001 for both), and use of renal replacement therapy (20% vs. 15%; p=0.005). After adjusting for age, race, sex, transplant listing status, and MELD-Na score, AoCKD was associated with a lower 90-day mortality compared to AKI-only (sub-HR 0.72 [95% CI 0.61, 0.87]).

Conclusion: In hospitalized patients with AKI and cirrhosis, AoCKD was associated with lower 90-day mortality compared to AKI-only. This may be due to 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.