Original Article
Pancreas, Biliary Tract, and Liver
Renal Trajectory Patterns Are Associated With Postdischarge Mortality in Patients With Cirrhosis and Acute Kidney Injury

https://doi.org/10.1016/j.cgh.2019.11.035Get rights and content

Background & Aims

Little is known about long-term outcomes of acute kidney injury (AKI) in patients with cirrhosis. Outcomes can vary with stage of AKI, chronic kidney disease, and trajectory of renal function.

Methods

We collected data from the Department of Veterans Affairs and identified 6917 patients with cirrhosis who developed AKI during hospitalization at any of its 127 hospitals, from 2004 through 2014. We used latent class analysis of serial creatinine measurements during the index hospitalization to determine trajectories of renal function.

Results

Overall, 32% of patients died within 90 days of discharge from the hospital and 48% of patients died within 1 year. We identified 5 distinct in-hospital renal trajectories: mild AKI with full improvement (24.8% of patients died 90 within days), severe AKI with rapid improvement (24.7% of patients died within 90 days), moderate AKI with partial improvement (33.7% of patients died within 90 days), moderate to severe AKI with partial improvement (42.0% of patients died within 90 days), and severe AKI with minimal improvement (48.0% of patients died within 90 days). Trajectories were associated significantly with mortality within 90 days and 1 year of mortality. Patients with severe AKI with minimal improvement had the highest risk of death within 90 days (adjusted odds ratio, 3.08; 95% CI, 2.54–3.72) and within 1 year (adjusted odds ratio, 2.71; 95% CI, 2.25–3.27) compared with patients with mild AKI with full improvement. The highest 90-day postdischarge mortality (65.2%) was observed in patients with normal or near-normal prehospitalization renal function who developed severe AKI with minimal improvement during hospitalization.

Conclusions

In an analysis of almost 7000 veterans with cirrhosis who were hospitalized for AKI, we found the pattern of renal trajectory to be associated with mortality after discharge. Renal trajectory patterns can be used to identify subgroups of patients with cirrhosis and AKI who should receive intensive postdischarge management.

Section snippets

Study Data and Patient Population

We acquired data from the Veterans Affairs (VA) Corporate Data Warehouse using VA Informatics and Computing Infrastructure workspace.8 We used VA Corporate Data Warehouse outpatient, inpatient, vital status (includes the date of death),9 and purchased care (includes services paid but provided outside of VA) files. The VA Vital Status file combines data from Medicare, VA, Social Security, and VA Compensation and Pension Benefits to determine the date of death (sensitivity of 98.3% and

Patient Characteristics

A total of 121,197 patients with cirrhosis were hospitalized at VA hospitals between January 1, 2004, and December 31, 2014. After excluding patients whose length of stay was shorter than 24 hours (n = 2643), who had liver or kidney transplant, had end-stage renal disease and dialysis (n = 5427) before the index hospitalization, and those who did not have an available baseline and second serum Cr to diagnose AKI (n = 39,214), a total of 73,913 patients with cirrhosis were identified. Among

Discussion

Our results show that in-hospital trajectory patterns (Figure 1) had an effect on 90-day and 1-year mortality (Table 2). We also found that pre-existing renal function (Supplementary Figure 2) was an important factor because, within each trajectory-based group, the outcomes differed based on pre-existing renal patterns (Figure 3). A subgroup of patients whose in-hospital trajectories returned to baseline renal pattern had better outcomes. However, others who presented with partial or minimal

Acknowledgments

Presented in abstract form on May 21, 2019, at Digestive Disease Week 2019, San Diego, California. Control ID: 3148648. Mindikoglu AL, Hernaez R, Liu Y, et al. Long-term outcomes in patients with acute kidney injury: a retrospective cohort study. Gastroenterology 2019;156:S-1348.

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    Conflicts of interest The authors disclose no conflicts.

    Funding The project was supported in part by the Center for Innovations in Quality, Effectiveness, and Safety (CIN 13-413), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. The project described also was supported in part by National Institutes of Health Public Health Service grant P30DK056338, which funds the Texas Medical Center Digestive Diseases Center. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institute of Diabetes and Digestive and Kidney Diseases or the National Institutes of Health.

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