Profile, Risk Factors and Outcome of Acute Kidney Injury in Paediatric Acute-on-chronic Liver Failure

Bikrant B. Lal; Seema Alam; Vikrant Sood; Dinesh Rawat; Rajeev Khanna


Liver International. 2018;38(10):1777-1784. 

In This Article

Abstract and Introduction


Background & Aims: There are no studies on acute kidney injury in paediatric acute-on-chronic liver failure. This study was planned with aim to describe the clinical presentation and outcome of acute kidney injury among paediatric acute-on-chronic liver failure patients.

Methods: Data of all children 1–18 years of age presenting with acute chronic liver failure (Asia pacific association for the study of the liver definition) was reviewed. Acute kidney injury was defined as per Kidney Diseases—Improving Global Outcomes guidelines. Poor outcome was defined as death or need for liver transplant within 3 months of development of acute kidney injury.

Results: A total of 84 children with acute-on-chronic liver failure were presented to us in the study period. Acute kidney injury developed in 22.6% of patients with acute-on-chronic liver failure. The median duration from acute-on-chronic liver failure to development of acute kidney injury was 4 weeks (Range: 2–10 weeks). The causes of acute kidney injury were hepatorenal syndrome (31.6%), sepsis (31.6%), nephrotoxic drugs (21%), dehydration (10.5%) and bile pigment related acute tubular necrosis in one patient. On univariate analysis, higher baseline bilirubin, higher international normalized ratio, higher paediatric end stage liver disease, presence of systemic inflammatory response syndrome and presence of spontaneous bacterial peritonitis had significant association with presence of acute kidney injury. On logistic regression analysis, presence of systemic inflammatory response syndrome (adjusted OR: 8.659, 95% CI: 2.18–34.37, P = .002) and higher baseline bilirubin (adjusted OR: 1.07, 95% CI: 1.008–1.135, P = .025) were independently associated with presence of acute kidney injury. Of the patients with acute kidney injury, 5(26.3%) survived with native liver, 10(52.6%) died and 4 (21.1%) underwent liver transplantation.

Conclusion: Acute kidney injury developed in 22.6% of children with acute-on-chronic liver failure. Bilirubin more than 17.7 mg/dL and presence of systemic inflammatory response syndrome were high risk factors for acute kidney injury. Development of acute kidney injury in a child with acute-on-chronic liver failure suggests poor outcome and need for early intervention.


Data on paediatric acute-on-chronic liver failure (ACLF) is scarce.[1–3] Kidney dysfunction is the single most important organ dysfunction associated with ACLF as per EASL-CLIF consortium.[4] Presence of organ failure is not a prerequisite for defining ACLF as per APASL which emphasizes on the potential for reversing progressive liver failure in the crucial "golden window" period, preventing development of sepsis and extrahepatic organ failures (including kidney).[5] AKI affects around 23–34% of ACLF in adults with prevalence as high as 51% in few studies.[6] As compared to patients with decompensated CLD, AKI is more common in ACLF patients, rapidly progressive and has worse outcome at 4 weeks.[7] This difference could be attributed to the difference in pathogenesis of AKI in ACLF where a major role is played by systemic inflammatory response syndrome (SIRS) and subsequent sepsis. It's also important to identify the predictors for development of AKI in ACLF as the outcome on medical management has been shown to be poor once AKI develops.[8] Presence of SIRS, high bilirubin, high MELD, ascites, spontaneous bacterial peritonitis (SBP), sepsis and acute variceal bleed have been linked to the development and progression of AKI in adult cirrhotics.[6,8–12] There are no studies till date to describe the prevalence, clinical profile and outcome of AKI in paediatric ACLF. In the present study, we aim to describe the presentation and outcome of AKI in paediatric ACLF.