The Natural History of Renal Function in Patients with Cirrhosis and Ascites Who Require Regular Large Volume Paracentesis

ABSTRACT

Background: Patients with decompensated cirrhosis and ascites are at risk for developing acute kidney injury (AKI), occurring in 20-49% of patients. Those with recurrent or refractory ascites requiring regular large volume paracentesis (LVPs) are at greater risk for AKI because of their advanced cirrhosis, abnormal hemodynamics and frequent fluid shifts from the LVPs. Aim(s) To assess the natural history of renal function in ascitic cirrhotic patients who require regular LVPs. Method(s) A single centre retrospective study including all ascitic cirrhotic patients who attended for outpatient regular LVPs from April 2020 to March 2021, excluding those with COVID infection, hepatocellular carcinoma exceeding Milan's criteria, or extensive non-liver malignancy. Data collected included demographics, paracentesis details, albumin infusions, renal function at baseline and during 3-month (M) follow-up, especially any AKI details, hospital admissions and survival. Result(s) 87 (M57, F30;62.0+/-11.3 yrs;MELD-Na 17.6+/-4.8) mostly alcoholic (47%) and NASH (25%) patients who attended for regular LVPs were included. 14 patients had history of variceal bleed, 26 had a history of encephalopathy (HE). Ascites had been present for 17+/-24M at enrolment, and 12 patients had prior spontaneous bacterial peritonitis. LVP had started 9+/-11M earlier. The mean # of LVPs was 4.2+/-2.6/M with 7.3+/-2.6L of ascites removed/LVP, receiving 90.5+/-38gm/M albumin with the LVPs. The mean serum creatinine (sCr) at enrolment was 100.9+/-50.3mumol/L, with 12 patients fulfilling the KDIGO's criteria for chronic kidney disease (CKD), due to diabetes or hypertension or both. 23 patients were diagnosed to have AKI at enrolment, 3 with background CKD. 5 patients required hospital admission. Table shows the details of AKI at enrolment. During 3M follow-up, 15 episodes of AKI (stage 1 n=9, stage 2 n=6) recurred in 11 patients, with the final sCr at 3M at 113+/-90mumol/L. 17 patients had 26 admissions in 3M, mostly related to cirrhosis complications (AKI/ HRS n=4, HE n=4;ascites related n=4, GI bleed n=4;infection (n=6). There was 1 liver transplant and 7 liver related deaths. Conclusion(s) CKD is becoming common among ascitic cirrhotic patients requiring LVPs. Irrespective of CKD presence, such patients frequently develop AKI, although mostly stage 1, but recur often, leading to gradual worsening of renal function within 3 M. This subset of patients needs close monitoring and future strategies to prevent AKIs.