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

OBJECTIVES: 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. SETTING: Academic tertiary care hospitals in the United States and Canada. DESIGN AND PATIENTS: 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. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: 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. CONCLUSIONS: 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.