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

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

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.