Author information

¹Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.

²Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.

³Department of Health Policy and Informatics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.

⁴Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.

⁵Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.

⁶Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, Edmonton, Canada.

⁷Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

⁸Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

⁹Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA.

¹⁰Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.

¹¹Division of Nephrology at the Medical College of Wisconsin, Milwaukee, WI, USA.

¹²Division of Nephrology and Hypertension, Weill Cornell College of Medicine, New York, NY, USA.

¹³Department of Gastroenterology and Transplant Hepatology at University of Michigan Health, Ann Arbor, MI, USA.

¹⁴Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA.

¹⁵Department of Nephrology at the Ochsner Medical Center, New Orleans, LA, USA.

¹⁶Department of Transplantation, Mayo Clinic, Jacksonville, Florida.

¹⁷Section of Nephrology, Department of Internal Medicine, Yale University and VA Connecticut Healthcare, New Haven, CT, USA.

Abstract

Background: While AKI requiring renal replacement therapy (AKI-RRT) is associated with increased mortality in heterogeneous inpatient populations, the epidemiology of AKI-RRT in hospitalized patients with cirrhosis is not fully known. Herein, we evaluated the association of etiology of AKI with mortality in hospitalized patients with cirrhosis and AKI-RRT in a multicentric contemporary cohort.

Methods: This is a multicenter retrospective cohort study using data from the HRS-HARMONY consortium, which included 11 U.S. hospital network systems. Consecutive adult patients admitted in 2019 with cirrhosis and AKI-RRT were included. The primary outcome was 90-day mortality, and the main independent variable was AKI etiology, classified as hepatorenal syndrome (HRS-AKI) vs. other (non-HRS-AKI). AKI etiology was determined by at least two independent adjudicators. We performed Fine and Gray sub-distribution hazard analyses adjusting for relevant clinical variables.

Results: Of 2,063 hospitalized patients with cirrhosis and AKI, 374 (18.1%) had AKI-RRT. Among these, 65 (17.4%) had HRS-AKI and 309 (82.6%) non-HRS-AKI, which included ATN in most cases (62.6%). Continuous RRT (CRRT) was used as the initial modality in 264 (71%) of patients, while intermittent hemodialysis (IHD) was utilized in 108 (29%). The HRS-AKI (vs. non-HRS-AKI) group received more vasoconstrictors for HRS management (81.5% vs. 67.9%), while the non-HRS-AKI group received more mechanical ventilation (64.3% vs. 50.8%) and more CRRT (vs. IHD) as the initial RRT modality (73.9% vs. 56.9%). In the adjusted model, HRS-AKI (vs. non-HRS-AKI) was not independently associated with increased 90-day mortality (sHR=1.36, 95% CI: 0.95-1.94).

Conclusions: In this multicenter contemporary cohort of hospitalized adult patients with cirrhosis and AKI-RRT, HRS-AKI was not independently associated with an increased risk of 90-day mortality when compared to other AKI etiologies. The etiology of AKI appears less relevant than previously considered when evaluating the prognosis of hospitalized adult patients with cirrhosis and AKI requiring RRT.