肝硬化和慢性肾脏病患者的急性肾损伤：HRS-HARMONY联盟的研究结果
Acute Kidney Injury in Patients with Cirrhosis and Chronic Kidney Disease: Results from the HRS-HARMONY Consortium.
作者信息
St Hillien Shelsea A, Robinson Jevon E, Ouyang Tianqi, Patidar Kavish R, Belcher Justin M, Cullaro Giuseppe, Regner Kevin R, Chung Raymond T, Ufere Nneka, Velez Juan Carlos Q, Neyra Javier A, Asrani Sumeet K, Wadei Hani, Teixeira J Pedro, Saly Danielle L, Levitsky Josh, Orman Eric, Sawinski Deirdre, Dageforde Leigh Anne, Allegretti Andrew S
机构信息
Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
出版信息
Clin Gastroenterol Hepatol. 2024 Dec 13. doi: 10.1016/j.cgh.2024.10.023.
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.
背景与目的
肝硬化患者中慢性肾脏病（CKD）的发病率正在上升，这些患者常并发急性肾损伤（AKI）。目前对于肝硬化患者中单纯AKI与慢性肾脏病基础上的急性肾损伤（AoCKD）之间的预后直接比较尚无详尽描述。
方法
对来自HRS-HARMONY联盟11个医院网络的2057例肝硬化合并AKI患者进行分析（70%为单纯AKI，30%为AoCKD）。主要结局指标为未校正及校正后的90天死亡率，并将移植作为竞争风险因素，采用Fine和Gray分析。
结果
与单纯AKI患者相比，AoCKD患者入院时肌酐中位数更高（2.25[四分位间距，1.7 - 3.2] vs 1.83[1.38 - 2.58]mg/dL），肌酐峰值也更高（2.79[2.12 - 4] vs 2.42[1.85 - 3.50]mg/dL），但肝功能参数更好（总胆红素1.5[四分位间距，0.7 - 3.1] vs 3.4[1.5 - 9.3]mg/dL；国际标准化比值1.4[四分位间距，1.2 - 1.8] vs 1.7[1.39 - 2.2]；所有P < 0.001）。AoCKD患者更易患代谢功能障碍相关脂肪性肝病肝硬化（31% vs 17%），而患酒精性肝病的可能性较小（26% vs 45%；两者P < 0.001）。单纯AKI患者未校正死亡率更高（39% vs 30%），重症监护病房入住率更高（52% vs 35%；两者P < 0.001），接受肾脏替代治疗的比例也更高（20% vs 15%；P = 0.005）。在对年龄、种族、性别、移植登记状态和终末期肝病-钠评分模型进行校正后，与单纯AKI相比，AoCKD患者90天死亡率更低（亚风险比，0.72；95%置信区间，0.61 - 0.87）。
结论
在住院的AKI合并肝硬化患者中，与单纯AKI相比，AoCKD患者90天死亡率更低。这可能是由于单纯AKI组较差的肝功能参数对短期预后产生的影响。需要进一步研究肝硬化中急性和慢性肾脏病之间复杂的相互作用。
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