New Update Focuses on Acute Kidney Injury Management in Cirrhosis

Acute kidney injury (AKI) in patients with cirrhosis is potentially preventable, and there are clear steps that can be taken to manage and reverse the condition, concludes a clinical practice update from the American Gastroenterological Association.

AKI occurs in 47% of patients hospitalized with complications of cirrhosis and in approximately 30% of outpatients with cirrhosis, resulting in a total cost in the United States of $4 billion, explained Patrick S. Kamath, MD, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, one of the authors of this update.

Moreover, Kamath told Medscape Medical News, among patients with cirrhosis and AKI, morbidity and mortality is sevenfold higher in comparison to those without cirrhosis, and repeated episodes of AKI increase the risk of progression to chronic kidney disease.

To provide practical advice for the clinical management of patients with cirrhosis and AKI, the authors conducted an expert review of the best available published evidence and gathered expert opinion.

The update was published online in Clinical Gastroenterology and Hepatology.

Some Key Takeaways

Among its 14 best practice statements, it describes three situations indicative of AKI:

  • A serum creatinine increase of ≥0.3 mg/dL within 48 hr

  • A serum creatinine increase of ≥50% from baseline

  • Reduction in urine output of <0.5 mL/kg/hr for >6 hr

The update also emphasizes the importance of an accurate diagnosis, inasmuch as not all cases of AKI are due to hepatorenal syndrome (HRS), for example. It goes on to advise that the specific type of AKI be identified through medical history and physical examination, as well as with blood biochemistry, urine microscopic examination, urine chemistry, selected urinary biomarkers, and renal ultrasound.

Additionally, it underscores the need to identify and treat infections and to closely monitor fluid status.

Nancy S. Reau, MD, Rush Medical College, Rush University, Chicago, Illinois, who was not involved in the update, commented to Medscape Medical News that fluid status is important when giving albumin replacement therapy because of the increased risk for pulmonary edema and ischemic complications.

Reau added that, for her, this update is more supportive of the use of the traditional HRS cocktail of midodrine, octreotide, and albumin than the American Association for the Study of Liver Diseases (AASLD) 2021 Practice Guidance, which “states that [the cocktail’s] efficacy is low and that these agents should only be used if terlipressin and/or norepinephrine are not available.”

While there is more agreement that dialysis is not recommended for patients who are not being considered for liver transplantation, Reau commented that the AASLD guidance is a little softer here and recommends that if dialysis is started, it should be with a clear goal or endpoint.

She also highlighted that this update advises against transjugular intrahepatic portosystemic shunts (TIPSs) as a specific treatment for HRS-AKI, noting that, although the 2022 North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension do not advocate for TIPS for this indication, they also indicated that there was enough evidence to advise against it.

In other key best practice advice statements, the update advises clinicians to hold diuretics and nonselective beta blockers and to discontinue nonsteroidal anti-inflammatory drugs (NSAIDs).

“Timely” Update

Overall, Reau believes that the update is “timely, especially in light of the recent [US] approval of terlipressin, which will change our treatment options.”

This update also supports the AASLD guidelines on HRS, she added.

Zobair Younossi, MD, MPH, professor of medicine, Virginia Commonwealth University, Inova Campus, Falls Church, Virginia, told Medscape Medical News that the update is important because of the huge increase in mortality among patients with cirrhosis and AKI.

He commented that there has been much advancement in understanding the condition, with updated nomenclature and novel medical treatments, and that this makes the update timely.

Moreover, the update will help clinicians who are involved in the care of patients with cirrhosis, he added.

Younossi said the update offers a very clearly stated algorithm for how to identify patients whose condition is easily reversible with volume repletion, in comparison with those patients who require medical treatment or even liver transplantation.

“Those things are important because that pathway gives clinicians an idea of how to do this properly,” he said.

“The key for clinicians is to make sure they understand, in the context of cirrhosis, some of the easy things that they can do to prevent AKI,” he continued. He added that the use of NSAIDs in these patients is “going to be problematic.”

Kamath has a relationship with Sequana Medical. Flamm has a relationship with Mallinckrodt Pharmaceutical Inc. Other authors’ relevant financial relationships are listed in the original article. Reau has relationships with Salix and Intercept. Younossi has disclosed no relevant financial relationships.

Clin Gastroenterol Hepatol. Published online September 5, 2022. Full text

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