Prospective validation of the EASL management algorithm for acute kidney injury in cirrhosis
Authors: Ann Thu Ma, Cristina Solé, Adrià Juanola, Laia Escudé, Laura Napoleone, Emma Avitabile, Martina Pérez-Guasch, Marta Carol, Enrico Pompili, Jordi Gratacós-Ginés, Anna Soria, Ana Belén Rubio, Marta Cervera, Maria José Moreta, Manuel Morales-Ruiz, Elsa Solà, Esteban Poch, Núria Fabrellas, Isabel Graupera, Elisa Pose, Pere Ginès
Journal: Journal of Hepatology (2024)

•The European Association for the Study of Liver published an algorithm for diagnosis/management of acute kidney injury in patients with cirrhosis. •This algorithm had not been validated in real practice thus far. •In this prospective cohort study, the use of this algorithm was associated with high renal response rates, both overall and in different phenotypes. •The use of the algorithm resulted in the swift diagnosis and treatment of hepatorenal syndrome. •These results support the use of this algorithm in clinical practice. Background and Aims The management of acute kidney injury (AKI) in cirrhosis is challenging. The EASL guidelines proposed an algorithm, but this has never been validated. We aimed to prospectively evaluate this algorithm in clinical practice. Methods Prospective cohort study of consecutive hospitalized patients with cirrhosis and AKI. EASL management algorithm includes identification/treatment of precipitating factors, 2-day albumin infusion in patients with AKI ≥ stage 1B, and treatment with terlipressin in patients with hepatorenal syndrome (HRS-AKI). Primary outcome was treatment response, which included both full and partial response. Secondary outcomes were survival and adverse events associated with terlipressin therapy. Results A total of 202 AKI episodes in 139 patients were included. Overall treatment response was 80%, while renal replacement therapy was required in only 8%. Response to albumin infusion was achieved in 1/3 of episodes. Of patients not responding to albumin, most (74%) did not meet the diagnostic criteria of HRS-AKI, with ATN being the most common phenotype. Response rate in patients not meeting criteria of HRS-AKI was 70%. Only 30 patients met the diagnostic criteria HRS-AKI, and response rate to terlipressin was 61%. Median time from AKI diagnosis to terlipressin initiation was only 2.5 days. While urinary neutrophil gelatinase-associated lipocalin (uNGAL) could differentiate acute tubular necrosis (ATN) vs other phenotypes (AUROC 0.78), it did not predict response to therapy in HRS-AKI. Ninety-day transplant-free survival was negatively associated with MELD-Na, ATN and HRS-AKI as well as uNGAL. Three patients treated with terlipressin developed pulmonary edema. Conclusions The application of the EASL AKI algorithm is associated with very good response rates and does not significantly delay initiation of terlipressin therapy. The management of acute kidney injury (AKI) in cirrhosis is challenging. The EASL guidelines proposed an algorithm, but this has never been validated. We aimed to prospectively evaluate this algorithm in clinical practice. Prospective cohort study of consecutive hospitalized patients with cirrhosis and AKI. EASL management algorithm includes identification/treatment of precipitating factors, 2-day albumin infusion in patients with AKI ≥ stage 1B, and treatment with terlipressin in patients with hepatorenal syndrome (HRS-AKI). Primary outcome was treatment response, which included both full and partial response. Secondary outcomes were survival and adverse events associated with terlipressin therapy. A total of 202 AKI episodes in 139 patients were included. Overall treatment response was 80%, while renal replacement therapy was required in only 8%. Response to albumin infusion was achieved in 1/3 of episodes. Of patients not responding to albumin, most (74%) did not meet the diagnostic criteria of HRS-AKI, with ATN being the most common phenotype. Response rate in patients not meeting criteria of HRS-AKI was 70%. Only 30 patients met the diagnostic criteria HRS-AKI, and response rate to terlipressin was 61%. Median time from AKI diagnosis to terlipressin initiation was only 2.5 days. While urinary neutrophil gelatinase-associated lipocalin (uNGAL) could differentiate acute tubular necrosis (ATN) vs other phenotypes (AUROC 0.78), it did not predict response to therapy in HRS-AKI. Ninety-day transplant-free survival was negatively associated with MELD-Na, ATN and HRS-AKI as well as uNGAL. Three patients treated with terlipressin developed pulmonary edema. The application of the EASL AKI algorithm is associated with very good response rates and does not significantly delay initiation of terlipressin therapy.