Significance of oliguria in critically ill patients with chronic liver disease

Amathieu, Roland; Al‐Khafaji, Ali; Sileanu, Florentina E.; Foldes, Emily; DeSensi, Rebecca; Hilmi, Ibtesam A.; Kellum, John A.

doi:10.1002/hep.29303

Cited by 83 publications

(65 citation statements)

References 22 publications

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“…However, the urine output was removed in the new consensus definition of AKI, which raised some arguments about the use of urine output in patients with cirrhosis. A recent study from the University of Pittsburgh reported that patients with oliguria had a nearly 3-fold increased rate of hospital mortality compared with patients without AKI in critically ill patients with chronic liver disease [22]. In our study, the predictive ability of ICA criteria was non-inferior to that of KDIGO, in spite of removal of urine output.…”

Section: Discussioncontrasting

confidence: 45%

Acute kidney injury in critically ill cirrhotic patients with spontaneous bacterial peritonitis: a comparison of KDIGO and ICA criteria

Xiong¹,

Zhang²,

Guo³

et al. 2020

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Section: Discussioncontrasting

confidence: 45%

Acute kidney injury in critically ill cirrhotic patients with spontaneous bacterial peritonitis: a comparison of KDIGO and ICA criteria

Xiong¹,

Zhang²,

Guo³

et al. 2020

aoms

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“…7 More recently it was observed that adding the urine output (UO) diagnostic criteria of AKI to the assessment of critically ill patients with chronic liver disease, in the intensive care unit, improved the identification of patients with AKI, as well as of those with stage 2-3 AKI. 33 Additionally, patients identified based on UO criteria without sCr elevation had a significantly higher mortality. 33 In patients with cirrhosis, as in patients without cirrhosis, AKI can be due to prerenal, intrarenal or intrinsic (acute tubular necrosis, acute interstitial nephritis, acute glomerular and vasculitic renal diseases) and/or post-renal (acute obstructive nephropathy) causes.…”

Section: What Is New In the Definition And Classification Of Renal Dymentioning

confidence: 99%

“…33 Additionally, patients identified based on UO criteria without sCr elevation had a significantly higher mortality. 33 In patients with cirrhosis, as in patients without cirrhosis, AKI can be due to prerenal, intrarenal or intrinsic (acute tubular necrosis, acute interstitial nephritis, acute glomerular and vasculitic renal diseases) and/or post-renal (acute obstructive nephropathy) causes. Additionally, HRS-1 should be included in the differential diagnosis.…”

Section: What Is New In the Definition And Classification Of Renal Dymentioning

confidence: 99%

News in pathophysiology, definition and classification of hepatorenal syndrome: A step beyond the International Club of Ascites (ICA) consensus document

Angeli

García–Tsao

Nadim

et al. 2019

Journal of Hepatology

330

299

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Renal dysfunction is a common, life-threatening complication occurring in patients with liver disease. Hepatorenal syndrome (HRS) has been defined as a purely ''functional" type of renal failure that often occurs in patients with cirrhosis in the setting of marked abnormalities in arterial circulation, as well as overactivity of the endogenous vasoactive systems. 4,5 In 2007, the International Club of Ascites (ICA) classified HRS into types 1 and 2 (HRS-1 and HRS-2). 5 HRS-1 is characterised by a rapid deterioration of renal function that often occurs because of a precipitating event, while HRS-2 is a moderate and stable or slowly progressive renal dysfunction that often occurs without an obvious precipitant. Clinically, HRS-1 is characterised by acute renal failure while HRS-2 is mainly characterised by refractory ascites. Nevertheless, after these two entities were first described, new concepts, definitions, and diagnostic criteria have been developed by nephrologists for renal dysfunction in the general population and hospitalised patients. In particular, the definitions and characterisation of acute kidney injury (AKI), acute kidney disease and chronic kidney disease have been introduced/refined. 6 Accordingly, a debate among hepatologists of the ICA led to a complete revision of the nomenclature and diagnosistic criteria for HRS-1, which was renamed HRS-AKI. 7 Additionally, over recent years, greater granularity has been gained regarding the pathogenesis of HRS; it is now increasingly recognised that it is not a purely ''functional" entity with haemodynamic derangements, but that systemic inflammation, oxidative stress and bile salt-related tubular damage may contribute significantly to its development. That is, HRS has an additional structural component that would not only make traditional diagnostic criteria less reliable, but would explain the lack of response to pharmacological treatment with vasoconstrictors plus albumin that correlates with a progressive increase in inflammation. Because classification, nomenclature, diagnostic criteria and pathogenic theories have evolved over the years since the traditional classification of HRS-1 and HRS-2 was first described, it was considered that all these novel aspects be reviewed and summarised in a position paper. The aim of this position paper authored by two hepatologists (members of ICA) and two nephrologists involved in the study of renal dysfunction in cirrhosis, is to complete the re-classification of HRS initiated by the ICA in 2012 and to provide an update on the definition, classification, diagnosis, pathophysiology and treatment of HRS.

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“…(4)(5)(6)(7) This is particularly true in those with AKI who then progress to persistent kidney injury, where the 30-day mortality rate is nearly 10-fold higher. (4,5,8) These findings highlight the importance of identifying the predictors of AKI as it is a potentially preventable and reversible condition. (9)(10)(11) To date, most studies evaluating AKI in patients with cirrhosis have included only those who are hospitalized.…”

mentioning

confidence: 96%

“…Regardless of the cause, the development of acute kidney injury (AKI) has a profound impact on survival . This is particularly true in those with AKI who then progress to persistent kidney injury, where the 30‐day mortality rate is nearly 10‐fold higher . These findings highlight the importance of identifying the predictors of AKI as it is a potentially preventable and reversible condition …”

mentioning

confidence: 99%

“Normal” Creatinine Levels Predict Persistent Kidney Injury and Waitlist Mortality in Outpatients With Cirrhosis

2018

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Acute kidney injury (AKI) is a critical determinant of outcomes in hospitalized patients with cirrhosis, but little is known of the impact of AKI in the outpatient setting. We analyzed 385 adult outpatients with cirrhosis listed for liver transplant at a single center; excluded were those with severe hepatic encephalopathy, with hepatocellular carcinoma, or on hemodialysis. Baseline serum creatinine (bCr) was defined as the lowest value recorded, peak Cr as the highest value, ΔCr as peak Cr minus bCr, AKI as a rise in serum Cr (sCr) by ≥0.3 mg/dL from bCr, persistent kidney injury as elevation of sCR by ≥0.3 mg/dL from bCr on each subsequent clinical assessment. Among 385 outpatients with cirrhosis, bCr was ≤0.70, 0.70-0.97, and ≥0.97 mg/dL in 28%, 38%, and 34%, respectively. At a median follow-up of 16 (range 8-28) months, 143 (37%) had one or more AKI episode, which increased significantly by bCr group (24% versus 37% versus 48%, P = 0.001). Of these 143 with AKI, 13% developed persistent kidney injury. A multivariable Cox regression analysis highlighted that bCr (hazard ratio [HR], 2.96) and ΔCr (HR, 2.05) were the only factors independently associated with the development of persistent kidney injury (P < 0.001). The likelihood of death/delisting increased by bCr group (14% versus 19% versus 28%, P = 0.03). A competing risk analysis demonstrated that each 1 mg/dL increase in bCr was independently associated with a 62% higher risk of death/delisting when accounting for transplantation and adjusting for confounders. Conclusion: AKI is not only common in outpatients with cirrhosis but even "clinically normal" bCr levels significantly impact the risk of persistent kidney injury and waitlist mortality, supporting the need for a lower clinical threshold to initiate monitoring of renal function and implementation of kidney-protective strategies.

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Significance of oliguria in critically ill patients with chronic liver disease

Abstract: CLD patients have a high incidence of AKI. Compared with creatinine criteria alone, incorporating UO into the diagnostic criteria increased the measured incidence of AKI. Stage 2-3 AKI-UO has a high negative impact on hospital mortality. (Hepatology 2017;66:1592-1600).

Cited by 83 publications

References 22 publications

Acute kidney injury in critically ill cirrhotic patients with spontaneous bacterial peritonitis: a comparison of KDIGO and ICA criteria

Acute kidney injury in critically ill cirrhotic patients with spontaneous bacterial peritonitis: a comparison of KDIGO and ICA criteria

News in pathophysiology, definition and classification of hepatorenal syndrome: A step beyond the International Club of Ascites (ICA) consensus document

“Normal” Creatinine Levels Predict Persistent Kidney Injury and Waitlist Mortality in Outpatients With Cirrhosis

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