University of Toronto, Department of Medicine, Division of Gastroenterology & Hepatology, Toronto, Ontario, Canada.
University of Pennsylvania, Department of Medicine, Division of Gastroenterology & Hepatology, Philadelphia, Pennsylvania.
Clin Gastroenterol Hepatol. 2021 Aug;19(8):1661-1669.e2. doi: 10.1016/j.cgh.2020.08.025. Epub 2020 Aug 13.
BACKGROUND & AIMS: Progression of stages 2 and 3 acute kidney injury (AKI) in cirrhosis has not been characterized adequately. Patients with higher stages of AKI are believed to have worse outcomes. We assessed outcomes and factors associated with stages 2 and 3 AKI in patients with cirrhosis in the North American Consortium for the Study of End-stage Liver Disease cohort.
We collected data from 2297 hospitalized patients with cirrhosis and ascites from December 2011 through February 2017. Our final analysis included 760 patients who developed AKI per the International Ascites Club 2015 definition (419 with maximum stage 1 and 341 with maximum stage 2 or 3; 63% male; mean age, 58 y). We compared demographic features, laboratory values, AKI treatment response, and survival between patients with maximum stage 1 vs patients with stage 2 or 3 AKI.
Patients with stage 2 or 3 AKI had higher Model for End-Stage Liver Disease scores (25.9 ± 7.3) than patients with stage 1 AKI (21.9 ± 7.5) (P < .0001). More patients fulfilled systemic inflammatory response syndrome criteria on admission, and more developed a second nosocomial infection (P < .05 for both comparisons). More patients with stage 2 or 3 AKI also had progression of AKI and required dialysis and admission into intensive care units when compared to stage 1 AKI patients (P < .0001 for both). A lower proportion of patients with stage 2 or 3 AKI survived their hospital stay (80% vs 99% with stage 1 AKI; P < .0001), or survived for 30 days without a liver transplant (56% vs 81%; P < .0001). The development of stage 2 or 3 AKI was associated with a higher Model for End-Stage Liver Disease score at the time of admission (P < .0001), presence of systemic inflammatory response on admission (P = .039), and second infection (P < .0001).
Based on an analysis of data from the North American Consortium for the Study of End-stage Liver Disease cohort, we found that patients with cirrhosis and more advanced liver disease, as well as a second infection, are more likely to develop stages 2 or 3 AKI, with a progressive course associated with decreased 30-day transplant-free survival. Prevention of AKI progression in patients with cirrhosis and stage 2 or 3 AKI might improve their outcomes.
肝硬化 2 期和 3 期急性肾损伤（AKI）的进展尚未得到充分描述。人们认为，AKI 程度较高的患者预后更差。我们评估了北美终末期肝病研究联盟队列中肝硬化患者的 AKI 2 期和 3 期的结局和相关因素。
我们收集了 2011 年 12 月至 2017 年 2 月期间住院的 2297 例肝硬化伴腹水患者的数据。我们的最终分析包括根据国际腹水俱乐部 2015 年定义发生 AKI 的 760 例患者（419 例最大分期 1 期，341 例最大分期 2 期或 3 期；63%为男性；平均年龄 58 岁）。我们比较了最大分期 1 期与最大分期 2 或 3 AKI 患者的人口统计学特征、实验室值、AKI 治疗反应和生存情况。
与最大分期 1 AKI 患者（21.9 ± 7.5）相比，最大分期 2 或 3 AKI 患者的终末期肝病模型评分更高（25.9 ± 7.3）（P <.0001）。更多的入院时满足全身炎症反应综合征标准的患者和更多的发生二次院内感染的患者（两者比较均 P <.05）。与最大分期 1 AKI 患者相比，更多的最大分期 2 或 3 AKI 患者的 AKI 也进展，需要透析和入住重症监护病房（两者比较均 P <.0001）。最大分期 2 或 3 AKI 患者的存活率较低（80%与最大分期 1 AKI 患者的 99%相比；P <.0001），或无肝移植 30 天存活率较低（56%与 81%；P <.0001）。最大分期 2 或 3 AKI 的发生与入院时更高的终末期肝病模型评分（P <.0001）、入院时存在全身炎症反应（P =.039）和第二次感染（P <.0001）相关。
基于对北美终末期肝病研究联盟队列数据的分析，我们发现肝硬化患者和更严重的肝脏疾病以及二次感染更有可能发展为 2 期或 3 期 AKI，其病程进展与 30 天无肝移植存活率降低相关。预防肝硬化和最大分期 2 或 3 AKI 患者的 AKI 进展可能会改善他们的预后。
