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ATM received funding from the Canadian Association for the Study of Liver and the Canadian Liver Foundation. This work has been supported by the ISCIII-Subdireccion General de Evaluacion and European Regional Development Fund for the Plan Nacional I+D+I (grant number PI20/00579 to PG) .

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Prospective validation of the EASL management algorithm for acute kidney injury in cirrhosis

Publicat a:Journal Of Hepatology. 81 (3): 441-450 - 2024-09-01 81(3), DOI: 10.1016/j.jhep.2024.03.006

Autors: Ma, AT; Juanola, A; Escudé, L; Napoleone, L; Avitabile, E; Pérez-Guasch, M; Carol, M; Pompili, E; Gratacós-Ginés, J; Soria, A; Rubio, AB; Cervera, M; Moreta, MJ; Graupera, I; Pose, E; Ginès, P; Fabrellas, N; Morales-Ruiz, M; Sola, E; Sole, C; Poch, E

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Background & Aims: 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. Methods: 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. 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 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. Conclusions: The application of the EASL AKI algorithm is associated with very good response rates and does not significantly delay initiation of terlipressin therapy. (c) 2024 The Authors. Published by Elsevier B.V. on behalf of European Association for the Study of the Liver. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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