The management of acute kidney injury (AKI) in cirrhosis is challenging. The EASL guidelines proposed an algorithm for the management of AKI, but this has never been validated. We aimed to prospectively evaluate this algorithm in clinical practice. We performed a prospective cohort study in consecutive hospitalized patients with cirrhosis and AKI. The 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). The 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 one-third of episodes. Of patients not responding to albumin, most (74%) did not meet the diagnostic criteria of HRS-AKI, with acute tubular necrosis (ATN) being the most common phenotype. The response rate in patients not meeting the criteria for HRS-AKI was 70%. Only 30 patients met the diagnostic criteria for HRS-AKI, and their response rate to terlipressin was 61%. Median time from AKI diagnosis to terlipressin initiation was only 2.5 days. While uNGAL (urinary neutrophil gelatinase-associated lipocalin) could differentiate ATN from 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. The occurrence of acute kidney injury (AKI) in patients with cirrhosis is associated with poor short-term mortality. Improving its rapid identification and prompt management was the focus of the recently proposed EASL AKI algorithm. This is the first prospective study demonstrating that high AKI response rates are achieved with the use of this algorithm, which includes identification of AKI, treatment of precipitating factors, a 2-day albumin challenge in patients with AKI ≥1B, and supportive therapy in patients with persistent AKI not meeting HRS-AKI criteria or terlipressin with albumin in those with HRS-AKI. These findings support the use of this algorithm in clinical practice.

中文翻译：

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EASL 管理算法对肝硬化急性肾损伤的前瞻性验证


肝硬化急性肾损伤（AKI）的治疗具有挑战性。 EASL 指南提出了一种 AKI 管理算法，但从未得到验证。我们的目的是在临床实践中前瞻性地评估该算法。我们对连续住院的肝硬化和 AKI 患者进行了一项前瞻性队列研究。 EASL 管理流程包括诱发因素的识别/治疗、AKI ≥ 1B 期患者的 2 天白蛋白输注以及肝肾综合征 (HRS-AKI) 患者的特利加压素治疗。主要结局是治疗反应，包括完全反应和部分反应。次要结局是生存率和与特利加压素治疗相关的不良事件。共纳入 139 名患者的 202 次 AKI 发作。总体治疗反应率为 80%，而只有 8% 需要肾脏替代治疗。三分之一的发作对白蛋白输注有反应。在对白蛋白无反应的患者中，大多数 (74%) 不符合 HRS-AKI 的诊断标准，其中急性肾小管坏死 (ATN) 是最常见的表型。不符合 HRS-AKI 标准的患者的缓解率为 70%。只有30名患者符合HRS-AKI的诊断标准，他们对特利加压素的缓解率为61%。从 AKI 诊断到开始使用特利加压素的中位时间仅为 2.5 天。虽然 uNGAL（尿中性粒细胞明胶酶相关脂质运载蛋白）可以将 ATN 与其他表型区分开来 (AUROC 0.78)，但它不能预测 HRS-AKI 治疗的反应。 90 天无移植生存率与 MELD-Na、ATN、HRS-AKI 以及 uNGAL 呈负相关。三名接受特利加压素治疗的患者出现肺水肿。 EASL AKI 算法的应用与非常好的反应率相关，并且不会显着延迟特利加压素治疗的开始。肝硬化患者发生急性肾损伤（AKI）与较低的短期死亡率相关。提高其快速识别和及时管理是最近提出的EASL AKI算法的重点。这是第一项前瞻性研究，证明使用该算法可实现高 AKI 缓解率，其中包括 AKI 的识别、诱发因素的治疗、AKI ≥1B 患者的 2 天白蛋白激发以及对患者的支持治疗不符合 HRS-AKI 标准的持续性 AKI 或 HRS-AKI 患者使用特利加压素和白蛋白。这些发现支持该算法在临床实践中的使用。