Validation of a Staging System for Acute Kidney Injury in Patients With Cirrhosis and Association With Acute-on-Chronic Liver Failure
Validation of a Staging System for Acute Kidney Injury in Patients With Cirrhosis and Association With Acute-on-Chronic Liver Failure
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DOI：
10.1016/j.cgh.2016.09.156
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发表时间：
2017-03-01
影响因子：
12.6
通讯作者：
Gines, Pere
中科院分区：
文献类型：
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作者：
Huelin, Patricia;Piano, Salvatore;Gines, Pere
背景与目的：在肝硬变患者中，急性肾损伤(AKI)分为3期。最近的研究表明，第一阶段疾病有两个亚型，与不同的预后和血清肌酐(Scr)水平有关：1A阶段(Scr<；1.5 mg/dl)和1B阶段(Scr>；=1.5 mg/dL)。我们进行了一项前瞻性研究，以验证这一新的描述与患者预后之间的关系，并评估AKI分期与急性-慢性肝功能衰竭之间的关系。方法：我们收集了2011年2月至2015年6月在两家三级医院(意大利和西班牙)连续住院的547名肝硬化急性失代偿期患者的数据。共有290名AKI患者(53%；197名患者为1期疾病)；AKI分期是根据诊断时的Scr水平确定的。对患者进行随访，直至死亡、肝移植或90天。结果：根据诊断时的Scr水平，58例患者为1A期疾病，139例为1B期疾病。在1A期患者中，82%的患者存活90天；在1B期患者中，55%的患者存活90天(P=.001)。肝肾综合征和急性肾小管坏死是1B期AKI最常见的原因，血容量不足是1A期AKI最常见的原因。在1B期患者中，AKI进展的比例高于1AKI期患者(31%对15%；P=.017)，而在1A期患者中，AKI消退的比例更高(1B期患者的90%对52%；P<；.001)。1B期疾病，而不是1A期，是AKI进展和死亡率的独立预测因子。1B期患者发生ACLF的比例(76%)明显高于1A期患者(22%；P<；.001)，这可以解释1B期患者预后较差的原因。结论：在一大组失代偿期肝硬变患者中，我们验证了AKI分期IA和IB(基于Scr水平)与生存时间和AKI进展的相关性。我们还发现AKI的这些亚型与急性-慢性肝功能衰竭的发生有关。这些发现对失代偿期肝硬变患者的治疗具有重要意义。
BACKGROUND & AIMS: In patients with cirrhosis of the liver, acute kidney injury (AKI) is classified into 3 stages. Recent studies indicate that there are 2 subgroups of stage 1 disease, associated with different outcomes and serum levels of creatinine (SCr): stage 1A (SCr < 1.5 mg/dL) and stage 1B (SCr >= 1.5 mg/dL). We performed a prospective study to validate, in a large series of patients with cirrhosis, the association between this new description and patient outcomes, and assess the relationship between AKI stage and the presence of acute-on-chronic liver failure.METHODS: We collected data from 547 consecutive patients admitted for cirrhosis with acute decompensation to 2 tertiary hospitals (Italy and Spain), from February 2011 through June 2015. A total of 290 patients had AKI (53%; 197 had stage 1 disease); AKI stages were determined based on levels of SCr at diagnosis. Patients were followed up until death, liver transplantation, or for 90 days. The primary outcome was 90-day survival; secondary outcomes were progression and resolution of AKI and association with acute-on-chronic liver failure.RESULTS: Based on level of sCr at diagnosis, 58 patients had stage 1A disease and 139 had stage 1B disease. Of patients with stage 1A disease, 82% survived for 90 days; of patients with stage 1B disease, 55% survived for 90 days (P = .001). Hepatorenal syndrome and acute tubular necrosis were the most common causes of stage 1B AKI, and hypovolemia was the most common cause of stage 1A AKI. AKI progressed in a higher proportion of patients with 1B than 1A AKI (31% vs 15%; P = .017) and resolved in a higher proportion of patients with 1A disease (90% vs 52% of patients with stage 1B; P < .001). Stage 1B disease, but not 1A, was an independent predictor of AKI progression and mortality. ACLF developed in a significantly greater proportion of patients with stage 1B disease (76%) than stage 1A disease (22%; P < .001), which could account for the poor outcomes of patients with stage 1B disease.CONCLUSIONS: In a large group of patients with decompensated cirrhosis, we validated the association between AKI stages IA and IB (based on level of sCR) with survival times and AKI progression. We also associated these subgroups of AKI with development of acute-on-chronic liver failure. These findings are important for management of patients with decompensated cirrhosis.