Association of HRS-AKI with Mortality in Patients with Cirrhosis Requiring Renal Replacement Therapy: Results from the HRS-HARMONY Consortium

Augusto Cama-Olivares; Tianqi Ouyang; Tomonori Takeuchi; Shelsea A St Hillien; Jevon E Robinson; Raymond T Chung; Giuseppe Cullaro; Constantine J Karvellas; Josh Levitsky; Eric S Orman; Kavish R Patidar; Kevin R Regner; Danielle L Saly; Deirdre Sawinski; Pratima Sharma; J Pedro Teixeira; Nneka N Ufere; Juan Carlos Q Velez; Hani M Wadei; Nabeel Wahid; Andrew S Allegretti; Javier A Neyra; Justin M Belcher; HRS-HARMONY Consortium

doi:10.34067/KID.0000000589

Association of HRS-AKI with Mortality in Patients with Cirrhosis Requiring Renal Replacement Therapy: Results from the HRS-HARMONY Consortium

Kidney360. 2024 Sep 30. doi: 10.34067/KID.0000000589. Online ahead of print.

Authors

Augusto Cama-Olivares¹, Tianqi Ouyang², Tomonori Takeuchi^{1

3}, Shelsea A St Hillien², Jevon E Robinson², Raymond T Chung⁴, Giuseppe Cullaro⁵, Constantine J Karvellas⁶, Josh Levitsky^{7

8}, Eric S Orman⁹, Kavish R Patidar¹⁰, Kevin R Regner¹¹, Danielle L Saly², Deirdre Sawinski¹², Pratima Sharma¹³, J Pedro Teixeira¹⁴, Nneka N Ufere⁴, Juan Carlos Q Velez¹⁵, Hani M Wadei¹⁶, Nabeel Wahid⁸, Andrew S Allegretti², Javier A Neyra¹, Justin M Belcher¹⁷; HRS-HARMONY Consortium

Affiliations

¹ Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
² Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
³ Department of Health Policy and Informatics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
⁴ Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
⁵ Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
⁶ Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, Edmonton, Canada.
⁷ Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
⁸ Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
⁹ Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA.
¹⁰ Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
¹¹ Division of Nephrology at the Medical College of Wisconsin, Milwaukee, WI, USA.
¹² Division of Nephrology and Hypertension, Weill Cornell College of Medicine, New York, NY, USA.
¹³ Department of Gastroenterology and Transplant Hepatology at University of Michigan Health, Ann Arbor, MI, USA.
¹⁴ Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA.
¹⁵ Department of Nephrology at the Ochsner Medical Center, New Orleans, LA, USA.
¹⁶ Department of Transplantation, Mayo Clinic, Jacksonville, Florida.
¹⁷ Section of Nephrology, Department of Internal Medicine, Yale University and VA Connecticut Healthcare, New Haven, CT, USA.

PMID: 39348201
DOI: 10.34067/KID.0000000589

Abstract

Background: While AKI requiring renal replacement therapy (AKI-RRT) is associated with increased mortality in heterogeneous inpatient populations, the epidemiology of AKI-RRT in hospitalized patients with cirrhosis is not fully known. Herein, we evaluated the association of etiology of AKI with mortality in hospitalized patients with cirrhosis and AKI-RRT in a multicentric contemporary cohort.

Methods: This is a multicenter retrospective cohort study using data from the HRS-HARMONY consortium, which included 11 U.S. hospital network systems. Consecutive adult patients admitted in 2019 with cirrhosis and AKI-RRT were included. The primary outcome was 90-day mortality, and the main independent variable was AKI etiology, classified as hepatorenal syndrome (HRS-AKI) vs. other (non-HRS-AKI). AKI etiology was determined by at least two independent adjudicators. We performed Fine and Gray sub-distribution hazard analyses adjusting for relevant clinical variables.

Results: Of 2,063 hospitalized patients with cirrhosis and AKI, 374 (18.1%) had AKI-RRT. Among these, 65 (17.4%) had HRS-AKI and 309 (82.6%) non-HRS-AKI, which included ATN in most cases (62.6%). Continuous RRT (CRRT) was used as the initial modality in 264 (71%) of patients, while intermittent hemodialysis (IHD) was utilized in 108 (29%). The HRS-AKI (vs. non-HRS-AKI) group received more vasoconstrictors for HRS management (81.5% vs. 67.9%), while the non-HRS-AKI group received more mechanical ventilation (64.3% vs. 50.8%) and more CRRT (vs. IHD) as the initial RRT modality (73.9% vs. 56.9%). In the adjusted model, HRS-AKI (vs. non-HRS-AKI) was not independently associated with increased 90-day mortality (sHR=1.36, 95% CI: 0.95-1.94).

Conclusions: In this multicenter contemporary cohort of hospitalized adult patients with cirrhosis and AKI-RRT, HRS-AKI was not independently associated with an increased risk of 90-day mortality when compared to other AKI etiologies. The etiology of AKI appears less relevant than previously considered when evaluating the prognosis of hospitalized adult patients with cirrhosis and AKI requiring RRT.