目的:急性肾损伤(AKI)在肝硬化病态,但不同病因的AKI在美国患者中的发病率并未得到很好的描述.我们比较了发病率,实践模式,以及肝硬化AKI病因的结局。
方法:对2019年收治的AKI和肝硬化连续成年患者的11家医院网络进行回顾性队列研究。AKI的病因是根据预先指定的临床定义(肾前/低血容量AKI,肝肾综合征[HRS-AKI],急性肾小管坏死[ATN],其他)。
结果:纳入2,063例患者(中位年龄62[IQR54,69]岁,38.3%女性,MELD-Na评分中位数2619,31)。最常见的AKI病因是肾前AKI(44.3%),其次是ATN(30.4%)和HRS-AKI(12.1%);6.0%有其他AKI,7.2%无法分类。8.1%的患者接受了肝移植,36.5%的人死亡90天。肾前AKI患者的死亡率最低(22.2%;p<0.001),而HRS-AKI和ATN患者的死亡率更高,但彼此之间没有显著差异(49.0%vs.52.7%;p=0.42)。使用肾前AKI作为参考,HRS-AKI(sHR2.78[95%CI2.18-3.54];p<0.001)和ATN(sHR2.83[2.36-3.41];p<0.001),90天死亡率的校正sHR较高.在调整后的分析中,较高的AKI分期和治疗无完全缓解与90天死亡风险增加相关(均p<0.001).
结论:AKI是肝硬化的严重并发症。HRS-AKI并不常见,结果与ATN相似。AKI的病因,AKI阶段/严重程度,治疗无应答与死亡率相关.需要进一步优化HRS-AKI的血管收缩剂和ATN的支持疗法。
■肝硬化中的急性肾损伤(AKI)具有很高的发病率,和管理是由损伤的病因决定的。然而,缺乏来自美国中心的使用更新的AKI定义的大型且规则良好的多中心数据库.我们的研究结果表明,急性肾小管坏死和肝肾综合征具有相似的结局(90天死亡率为50%)。尽管肝肾综合征并不常见(占所有AKI病例的12%)。这些发现代表了美国移植/三级中心的实践模式,可用作美国采用特利加压素之前的基线。
Acute kidney injury (AKI) in cirrhosis is common and associated with high morbidity, but the incidence rates of different etiologies of AKI are not well described in the US. We compared incidence rates, practice patterns, and outcomes across etiologies of AKI in cirrhosis.
We performed a retrospective cohort study of 11 hospital networks, including consecutive adult patients admitted with AKI and cirrhosis in 2019. The etiology of AKI was adjudicated based on pre-specified clinical definitions (prerenal/hypovolemic AKI, hepatorenal syndrome [HRS-AKI], acute tubular necrosis [ATN], other).
A total of 2,063 patients were included (median age 62 [IQR 54-69] years, 38.3% female, median MELD-Na score 26 [19-31]). The most common etiology was prerenal AKI (44.3%), followed by ATN (30.4%) and HRS-AKI (12.1%); 6.0% had other AKI, and 7.2% could not be classified. In our cohort, 8.1% of patients received a liver transplant and 36.5% died by 90 days. The lowest rate of death was observed in patients with prerenal AKI (22.2%; p <0.001), while death rates were higher but not significantly different from each other in those with HRS-AKI and ATN (49.0% vs. 52.7%; p = 0.42). Using prerenal AKI as a reference, the adjusted subdistribution hazard ratio (sHR) for 90-day mortality was higher for HRS-AKI (sHR 2.78; 95% CI 2.18-3.54; p <0.001) and ATN (sHR 2.83; 95% CI 2.36-3.41; p <0.001). In adjusted analysis, higher AKI stage and lack of complete response to treatment were associated with an increased risk of 90-day mortality (p <0.001 for all).
AKI is a severe complication of cirrhosis. HRS-AKI is uncommon and is associated with similar outcomes to ATN. The etiology of AKI, AKI stage/severity, and non-response to treatment were associated with mortality. Further optimization of vasoconstrictors for HRS-AKI and supportive therapies for ATN are needed.
Acute kidney injury (AKI) in cirrhosis carries high morbidity, and management is determined by the etiology of injury. However, a large and well-adjudicated multicenter database from US centers that uses updated AKI definitions is lacking. Our findings demonstrate that acute tubular necrosis and hepatorenal syndrome have similar outcomes (∼50% mortality at 90 days), though hepatorenal syndrome is uncommon (12% of all AKI cases). These findings represent practice patterns at US transplant/tertiary centers and can be used as a baseline, presenting the situation prior to the adoption of terlipressin in the US.