Gowda Yashavanth H S, Jagtap Nitin, Karyampudi Arun, Rao Nagaraja P, Deepika Gujjarapudi, Sharma Mithun, Gupta Rajesh, Tandan Manu, Ramchandani Mohan, John Priyadarshini, Kulkarni Anand, Kumar Pramod, Bhaware Bhushan, Turpati Mohan V, Reddy D Nageshwar
Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India.
Department of Biochemistry, Asian Institute of Gastroenterology, Hyderabad, India.
J Clin Exp Hepatol. 2022 May-Jun;12(3):899-907. doi: 10.1016/j.jceh.2021.09.019. Epub 2021 Sep 28.
Prerenal acute kidney injury (prerenal AKI), hepatorenal syndrome (HRS-AKI), and acute tubular necrosis (ATN-AKI) are the various phenotypes of acute kidney injury, which are described in decompensated cirrhosis. It has therapeutic and prognostic implications. We aimed to evaluate the diagnostic utility of fractional excretion of sodium and urea (FENa and FEUrea) for differentiating AKI phenotypes.
A prospective analysis was performed in 200 patients with decompensated cirrhosis with AKI to derive receiver operating curve, optimal cut-off, sensitivity, and specificity. These findings were validated in an independent cohort (n = 50) to differentiate ATN-AKI, HRS-AKI, and prerenal AKI.
The incidence of prerenal AKI, HRS-AKI, and ATN-AKI were 37.5%, 34%, and 28.5% in the derivation cohort and 28%, 38%, and 34% in the validation cohort respectively. The median FENa was significantly different in various phenotypes of AKI in the derivation and validation cohort ( 0.001); FEUrea was significantly different in the derivation cohort ( 0.0001), not in the validation cohort ( 0.106). The AUC for FENa (cut-off, sensitivity/specificity) was 86.6% (0.567, 89/71) and for FEUrea was 60.3% (34.73, 70/58) for ATN-AKI vs. non-ATN-AKI. The area under the curve for FENa to differentiate between HRS-AKI vs. non-HRS-AKI was 74.5%. FEUrea could not differentiate HRS-AKI vs. non-HRS-AKI (AUC 60.4%) satisfactorily. FENa and FEUrea were unable to differentiate between prerenal AKI and HRS-AKI (AUC <70%).
Among cirrhotics FENa at admission is a simple, commonly available clinical tool that can be used to differentiate structural AKI from prerenal AKI and HRS-AKI. The newly derived lowered cut-off value of FENa makes the diagnosis of ATN-AKI easier, faster and thus obviates the need for extensive workup in a significant proportion of patients. FENa appears better than FEUrea in decompensated cirrhosis with AKI.
肾前性急性肾损伤（prerenal AKI）、肝肾综合征（HRS - AKI）和急性肾小管坏死（ATN - AKI）是急性肾损伤的不同表型，在失代偿期肝硬化中有所描述。这具有治疗和预后意义。我们旨在评估钠和尿素分数排泄率（FENa和FEUrea）对区分急性肾损伤表型的诊断效用。
对200例患有急性肾损伤的失代偿期肝硬化患者进行前瞻性分析，以得出受试者工作特征曲线、最佳截断值、敏感性和特异性。这些结果在一个独立队列（n = 50）中进行验证，以区分ATN - AKI、HRS - AKI和肾前性AKI。
在推导队列中，肾前性AKI、HRS - AKI和ATN - AKI的发生率分别为37.5%、34%和28.5%，在验证队列中分别为28%、38%和34%。在推导队列和验证队列中，不同急性肾损伤表型的FENa中位数有显著差异（P < 0.001）；FEUrea在推导队列中有显著差异（P < 0.0001），在验证队列中无显著差异（P = 0.106）。对于ATN - AKI与非ATN - AKI，FENa的曲线下面积（截断值、敏感性/特异性）为86.6%（0.567，89/71），FEUrea为60.3%（34.73，70/58）。FENa区分HRS - AKI与非HRS - AKI的曲线下面积为74.5%。FEUrea不能令人满意地区分HRS - AKI与非HRS - AKI（曲线下面积60.4%）。FENa和FEUrea无法区分肾前性AKI和HRS - AKI（曲线下面积<70%）。
在肝硬化患者中，入院时的FENa是一种简单、常用的临床工具，可用于区分结构性急性肾损伤与肾前性AKI和HRS - AKI。新推导的降低的FENa截断值使ATN - AKI的诊断更简便、快速，从而在很大比例的患者中无需进行广泛的检查。在患有急性肾损伤的失代偿期肝硬化中，FENa似乎比FEUrea更好。
