Spotlight on acute kidney injury in cirrhosis

Two recent articles looked at acute kidney injury (AKI) in patients with cirrhosis.

The first, a cohort study published by the Journal of Hepatology on Oct. 19, focused on patients with and without cirrhosis who were undergoing contrast-enhanced computed tomography (CECT). It included 148 patients with cirrhosis and 163 without cirrhosis who received CECT and 133 patients with cirrhosis who did not get CECT. Based on repeated assessments of kidney function from scanning to a week later, AKI risk was not significantly greater in patients with cirrhosis undergoing CECT (4.8% vs. 2.5% in those scanned without cirrhosis and 1.5% in those with cirrhosis not undergoing CECT). The presence of concomitant infection was the only independent factor that predicted AKI in cirrhosis patients undergoing CT (odds ratio, 22.18 [95% CI, 2.87 to 171.22]; P=0.003). Most AKI cases were mild and transient, the study authors noted.

“Our results show that [contrast-induced] AKI risk in cirrhosis is limited (4.8%), lower than that reported by several previous studies, and not significantly different from the risk observed in the general population,” said the study authors. They noted that given the rate of AKI in patients with cirrhosis who didn't receive contrast, at least some of the AKI episodes in the CECT group might be unrelated to the receipt of contrast. The study authors added that the recommendation to be cautious about the use of contrast imaging in patients with cirrhosis “does not seem reasonable anymore” except in the presence of infection.

The other article, published in the September Clinical Gastroenterology and Hepatology, was a review of the diagnosis and nonpharmacological management of AKI in patients with cirrhosis. It reviewed the types of AKI in patients with cirrhosis, noting that serum creatinine and urine output “remain the mainstays of diagnosis of AKI,” including in patients with hepatorenal syndrome, and that the criteria should be change in creatinine from baseline, rather than any specific threshold value.

The review of management covered appropriate supportive care and nonpharmacological treatment options, including renal replacement therapy, transjugular intrahepatic portosystemic shunts, extracorporeal liver support systems, and liver transplantation. Finally, the review discussed prevention of AKI in patients with cirrhosis, highlighting avoidance of NSAIDs, repletion of volume, and careful selection of contrast agents as potential strategies. “Although early diagnosis is the critical first step and the key to ensure optimal management, measures should be taken to prevent AKI in patients with cirrhosis,” the review concluded.