Observational Study
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World J Hepatol. Mar 27, 2022; 14(3): 592-601
Published online Mar 27, 2022. doi: 10.4254/wjh.v14.i3.592
Predictors of mortality at 28-days in infection associated acute kidney injury in cirrhosis
Tarana Gupta, Naveen Ranga, Sandeep Kumar Goyal
Tarana Gupta, Naveen Ranga, Department of Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak 124001, Haryana, India
Sandeep Kumar Goyal, Independent Researcher, Kangra 176056, Himachal Pradesh, India
Author contributions: Gupta T was the guarantor and designed the study; Ranga N was involved in acquisition of data and drafted the initial manuscript; Goyal SK performed statistical analysis and interpretation of data; Gupta T revised the manuscript critically for important intellectual content.
Institutional review board statement: The study was reviewed and approved by the institutional ethics committee at Pt. BD Sharma Institute of Medical Sciences, Rohtak (India).
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: There are no conflicts of interest to report.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Tarana Gupta, MBBS, MD, Doctor, Professor, Department of Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Medical Mor, Rohtak 124001, Haryana, India. taranagupta@gmail.com
Received: May 18, 2021
Peer-review started: May 18, 2021
First decision: June 22, 2021
Revised: July 4, 2021
Accepted: February 15, 2022
Article in press: February 15, 2022
Published online: March 27, 2022
Processing time: 309 Days and 22.4 Hours
Abstract
BACKGROUND

Acute kidney injury (AKI) in cirrhosis is important complication with poor outcomes. And infections are common cause for acute decompensation. Infections in cirrhosis lead to acute deterioration of hemodynamics leading to precipitation of AKI.

AIM

To study predictors of mortality in patients with infection-associated AKI in cirrhosis.

METHODS

This was a prospective, observational study conducted at tertiary care centre from January 2018 till April 2019. Total 119 participants with cirrhosis of liver presenting with AKI were included into the study. AKI was defined as per international club of Ascites-AKI criteria 2015. Patients were grouped into infection AKI and non-infection AKI. Non-infection AKI included patients with diuretic induced AKI and pre-renal AKI. Logistic regression analysis was used to determine predictors of mortality at 28-d.

RESULTS

Out of 119 patients, alcohol (n = 104) was most common etiology of cirrhosis. The infection AKI included 67 (56%) patients and non-infection AKI (n = 52) included pre-renal AKI in 36 (30%) and diuretic-induced AKI in 16 (14%) patients. Infection AKI had significantly higher bilirubin, higher international normalized ratio (INR), low serum sodium, higher total leukocyte count (TLC) and higher prevalence of hepatic encephalopathy (HE) as compared to non-infection AKI. Infection AKI had higher progression of AKI (19/67 vs 2/52; P = 0.01) and 28-d mortality (38/67 vs 4/5; P ≤ 0.01) as compared to non-infection AKI. At 28-d, non-survivors (n = 42) had significantly higher bilirubin, higher INR, low serum sodium, higher TLC and higher prevalence of HE as compared to survivors (n = 77). On subgroup analysis of Infection AKI group, on multivariate analysis, serum bilirubin as well as presence of HE were independent predictors of 28-d mortality. There was no significant difference of mortality at 90-d between two groups.

CONCLUSION

Infection AKI in cirrhosis has a dismal prognosis with higher 28-d mortality as compared to non-infection AKI. Serum bilirubin and presence of HE predict 28-d mortality in infection AKI.

Keywords: Infection; Acute kidney injury; Mortality; Cirrhosis; Bilirubin; Hepatic encephalopathy

Core Tip: The infections in cirrhosis are the most common cause for acute decompensation and organ failure. Acute kidney injury (AKI) in cirrhosis is itself an indicator for worsening hemodynamics. In the present study, we compared infection associated AKI and non-infection AKI. We found higher 28-d mortality in infection AKI than non-infection AKI. In addition to altered hemodynamics, pathogen associated molecular patterns and damage-associated molecular patterns produced as a result of sepsis contribute to multiorgan failure, especially renal dysfunction. Moreover, higher bilirubin and presence of hepatic encephalopathy predicted 28-d mortality in patients with infection AKI. This provides an insight that the combination of infection and AKI in cirrhosis portends a dismal prognosis and therefore, on admission, early identification of infection and aggressive management may improve outcome in these patients.