Epidemiology of Critically Ill Patients With Cirrhosis Undergoing Continuous Renal Replacement Therapy: A Contemporaneous Parallel Analysis of the HRS-HARMONY and CRRTnet Registries.

Abstract

Describe the epidemiology of patients with cirrhosis/acute-on-chronic liver failure (ACLF) receiving continuous renal replacement therapy (CRRT) pertaining to process factors including renal replacement dose, modality, and circuit anticoagulation. Academic tertiary care hospitals in the United States and Canada. We performed a parallel study of contemporaneous data from the HARMONY and CRRT network (CRRTnet) databases to describe the epidemiology and process of CRRT care of cirrhosis/ACLF patients receiving CRRT in the ICU. We evaluated clinical and CRRT process factors (dialysis dose, anticoagulation) with the primary outcome of in-hospital mortality. None. The HARMONY cohort (n = 245; median age, 57 yr; 41% female) and CRRTnet cohort (n = 206; 58 yr; 39% female) demonstrated similar overall survival to hospital discharge (HARMONY, 34%; CRRTnet, 30%). In HARMONY, the two most common causes of acute kidney injury (AKI) requiring CRRT were acute tubular necrosis (73%) and hepatorenal syndrome-AKI (13%), with no significant difference between survivors and nonsurvivors (p = 0.24). In HARMONY, higher chronic liver failure-C ACLF scores (hazard ratio, 1.03 [95% CI, 1.01-1.05]; p < 0.001) were independently associated with increased in-hospital mortality. In CRRTnet, the most common CRRT modality was continuous venovenous hemodiafiltration (83.8%), and the most common anticoagulation strategy was regional citrate anticoagulation (58.0%) or no anticoagulation (35.8%). CRRT prescribed dose greater than 30 mL/kg/hr was independently associated with higher in-hospital mortality (multivariable regression; odds ratio, 2.69; 95% CI, 1.3-5.64; p = 0.01). Of survivors in CRRTnet, 64% were transitioned to intermittent hemodialysis (IHD) before hospital discharge. Critically ill cirrhosis/ACLF patients initiated on CRRT in the absence of liver transplantation had high in-hospital mortality. These patients were prescribed higher initial CRRT doses (median total effluent > 30 mL/kg/hr), with higher CRRT dose independently associated with increased in-hospital mortality. Of ICU survivors, 64% were transitioned to IHD at ICU discharge. Despite concerns for citrate toxicity, citrate regional anticoagulation was commonly employed in these patients.