on demand versus protocol-guided renal replacement therapy for management of stage 3 acute kidney injury in patients with cirrhosis

Conditions: Acute Kidney Injury With Cirrhosis

Summary: intervention: all patients at presentation would be assessed for the underlying cause of and will be managed by removal of all precipitants(careful review of medications, diuretics, nephrotoxic drugs,vasodilators or non-steroidal anti-inflammatory drugs). the second step would be to consider plasma volume expansion in patients with hypovolemia (the choice of fluid could either be a crystalloid or albumin or even blood as indicated) along with identification and early treatment of bacterial infections. along with this patients with a differential diagnosis of hrs-aki would be given terlipressin ( or noradrenaline/octreotide midodrine in case of contraindication to terlipressin). patients with a clinical diagnosis of atn would be randomized to the on-demand versus protocol-guided dialysis groups. further, patients with urine output of less than 0.5ml/kg/hour for 4-6 hours despite adequate fluid resuscitation and vasoconstrictors would also be subjected to randomization. 1. in the on-demand group patients would get dialysis only when patient fulfills absolute criteria requiring dialysis such as metabolic acidosis with ph\<7.2, hyperkalemia, refractory fluid overload (non-responsive to diuretics) or oliguria with urine output of less than 0.5ml/kg for more than 24-48 hours from the time of randomization 2. in the protocol guided group patients all patients would be considered for dialysis within 6 hours of randomization after randomization patients would receive dialysis as three sessions per week of at least 4 h with a blood flow \>200 ml/min and a dialysate flow \>500 ml/min in intermittent group and as 20-25 ml/kg/h of effluent, by filtration and/or diffusion in continuous form until recovery of renal functions


Eligibility criteria:
inclusion criteria: * patients with cirrhosis (diagnosed based on clinical, biochemical,radiological or histological diagnosis) with stage 3 acute kidney injury defined as an increase of serum creatinine to more than 300 fold and more than 4 mg/dl. exclusion criteria: * patients with age less than 18 years * severe known cardiopulmonary disease (structural or valvular heart disease, coronary artery disease, copd chronic obstructive pulmonary disease) * pregnancy * chronic kidney disease on hemodialysis * patients with post renal obstructive aki (acute kidney injury), aki (acute kidney injury) suspected due to glomerulonephritis, interstitial nephritis or vasculitis based on clinical history and urine analysis * patients already meeting emergency criteria for immediate hemodialysis at the time of randomization (serum potassium\>6 meq/lt, metabolic acidosis ph\<7.12, acute pulmonary edema, severe volume overload with hypoxemia non-responsive to diuretic treatment) * patients transferred from other hospitals who have already been on hemodialysis before their arrival in the intensive care unit * extremely moribund patients with an expected life expectancy of less than 24 hours * failure to give informed consent from family members. * hemodynamic instability requiring very high dose of vasopressors.