Acute Kidney Injury in Cirrhosis

Definition and Diagnostic Criteria

The International Club of Ascites recommends diagnosing ICA-AKI in patients with cirrhosis using adapted KDIGO criteria, which includes an increase in serum creatinine of >0.3 mg/dl from baseline within 48 hours, or an increase of ≥50% from baseline within three months 1
ICA-AKI is further staged according to modified KDIGO staging, with stage 1 subdivided into 1A and 1B, which guides management decisions 2
The Kidney Disease: Improving Global Outcomes (KDIGO) criteria are used to diagnose normal AKI, without the cirrhosis-specific modifications 3

ICA-AKI occurs in the setting of cirrhosis, where splanchnic vasodilation, decreased effective arterial blood volume, and activation of vasoconstrictor systems create a unique hemodynamic environment 2, 4
ICA-AKI includes specific subtypes like hepatorenal syndrome (HRS-AKI), which is a functional form of AKI characterized by intense renal arteriolar vasoconstriction in the absence of structural kidney damage 5, 6

For ICA-AKI stage 1A, the European Association for the Study of the Liver recommends reviewing medications, withdrawing diuretics, discontinuing nephrotoxic drugs, vasodilators, and NSAIDs, and providing plasma volume expansion for suspected hypovolemia 8, 5
For ICA-AKI stage 1B, 2, or 3, the American Association for the Study of Liver Diseases recommends administering 20% albumin solution at 1 g/kg body weight for two consecutive days, and initiating vasoconstrictors (terlipressin) plus albumin if no response after 2 days and meets HRS criteria 2, 4, 9

In ICA-AKI, urinary NGAL can help distinguish between ATN and HRS, which is crucial for treatment decisions, according to the International Club of Ascites 2
Kidney biopsy is rarely performed in ICA-AKI, making biomarkers particularly important, as stated by the European Association for the Study of the Liver 2

ICA-AKI has a significant negative impact on hospital survival, with mortality related to both initial and peak AKI stage, according to the American Association for the Study of Liver Diseases 2
Even transient episodes of ICA-AKI negatively affect mid-term survival, as reported by the European Association for the Study of the Liver 2

ICA-AKI prevention includes albumin infusion with therapeutic paracentesis, antibiotic prophylaxis for spontaneous bacterial peritonitis, careful monitoring when using diuretics, and avoiding nephrotoxic medications and NSAIDs, as recommended by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver 2, 6