The prognostic impact of acute kidney injury recovery patterns in critically Ill patients with cirrhosis.

BACKGROUND: The prognostic impact of acute kidney injury (AKI) recovery patterns in critically ill patients with cirrhosis is unknown. We aimed to compare mortality stratified by AKI-recovery patterns and identify predictors of mortality in patients with cirrhosis and AKI admitted to the intensive care unit (ICU).

METHODS: Patients with cirrhosis and AKI from 2016-2018 at two tertiary-care ICUs were analyzed (N=322). AKI-recovery was defined by Acute Disease Quality Initiative (ADQI) consensus: return of serum creatinine <0.3 mg/dL of baseline within 7 days of AKI onset. Recovery patterns were categorized by ADQI-consensus: 0-2-days, 3-7 days, and no-recovery (persistence of AKI >7 d). Landmark competing-risk univariable and multivariable models (liver-transplant as competing-risk) was used to compare 90-day mortality between AKI-recovery groups and to determine independent predictors of mortality.

RESULTS: 16% (N=50) and 27% (N=88) achieved AKI-recovery within 0-2 and 3-7 days, respectively; 57% (N=184) had no-recovery. Acute on chronic liver failure (ACLF) was prevalent (83%) and patients with no-recovery were more likely to have grade-3 ACLF (N=95, 52%) compared to patients with AKI-recovery [0-2: 16% (N=8); 3-7: 26% (N=23); P<0.001]. Patients with no-recovery had significantly higher probability of mortality [unadjusted-sHR 3.55 (95%CI 1.94-6.49), P<0.001] compared to patients with recovery within 0-2-days, while the probability was similar between 3-7 and 0-2 days [unadjusted-sHR 1.71 (95%CI 0.91-3.20), P=0.09]. On multivariable analysis, AKI no-recovery [sHR 2.07 (95%CI 1.33-3.24), P=0.001)], severe alcohol-associated hepatitis [sHR 2.41 (95%CI 1.20-4.83), P=0.01], and ascites [sHR 1.60 (95%CI 1.05-2.44), P=0.03] were independently associated with mortality.

CONCLUSION: AKI no-recovery occurs in over half of critically ill patients with cirrhosis and AKI and is associated with worse survival. Interventions that facilitate AKI-recovery may improve outcomes in this patient population.