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Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites
  1. Paolo Angeli1,
  2. Pere Gines2,3,4,5,
  3. Florence Wong6,
  4. Mauro Bernardi7,
  5. Thomas D Boyer8,
  6. Alexander Gerbes9,
  7. Richard Moreau10,11,12,
  8. Rajiv Jalan13,
  9. Shiv K Sarin14,
  10. Salvatore Piano1,
  11. Kevin Moore15,
  12. Samuel S Lee16,
  13. Francois Durand17,18,
  14. Francesco Salerno19,
  15. Paolo Caraceni7,
  16. W Ray Kim20,
  17. Vicente Arroyo2,3,4,
  18. Guadalupe Garcia-Tsao21
  1. 1Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine—DIMED, University of Padova, Padova, Italy
  2. 2Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain
  3. 3Institut d'Investigacions Biomediques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain
  4. 4Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
  5. 5Instituto Reina Sofia d'Investigación en Nefrologia (IRSIN), Barcelona, Spain
  6. 6Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
  7. 7Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
  8. 8Department of Medicine, Liver Research Institute, University of Arizona, College of Medicine, Tucson, Arizona, USA
  9. 9Liver Unit, Klinikum Munich, Ludwig Maximilian University of Munich, Munich, Germany
  10. 10Inserm U1149, Centre de recherche sur l'Inflammation (CRI), Paris, France
  11. 11UMR S_1149, Université Paris Diderot, Paris, France
  12. 12DHU UNITY, Service d'hépatologie, Hôpital Beaujon, APHP, Clichy, France
  13. 13Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
  14. 14Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
  15. 15UCL Institute of Liver and Digestive Health, Royal Free Campus, University College London, London, UK
  16. 16Liver Unit, University of Calgary, Calgary, Canada
  17. 17Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France
  18. 18INSERM U773, Centre de Recherche Biomédicale Bichat Beaujon CRB3, Clichy, France
  19. 19Policlinico IRCCS San Donato, Medicina Interna ed Epatologia, Università di Milano, Milan, Italy
  20. 20Division of Gastroenterology and Hepatology, Stanford University Medical School, Palo Alto, California, USA
  21. 21Division of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
  1. Correspondence to Professor Paolo Angeli, Department of Medicine (DIMED) and Unit of Hepatic Emergencies and Liver Transplantation, University of Padova, Via Giustiniani 2, Padova 35100, Italy; pangeli{at}

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Acute renal failure (ARF) is a common complication in patients with decompensated cirrhosis. The traditional diagnostic criteria of renal failure in these patients were proposed in 19961 and have been refined in subsequent years.2 According to these criteria, ARF is defined as an increase in serum creatinine (sCr) of ≥50% from baseline to a final value >1.5 mg/dL (133 µmol/L). However, the threshold value of 1.5 mg/dL (133 µmol/L) sCr to define renal failure in patients with decompensated cirrhosis has been challenged.3 ,4 In addition, the timeframe to distinguish acute from chronic renal failure has not been clearly identified, the only exception being type 1 hepatorenal syndrome (HRS). Meanwhile, new definitions for ARF, now termed acute kidney injury (AKI), have been proposed and validated in patients without cirrhosis.5–7 Recently these new criteria were also proposed and applied in the diagnosis of AKI in patients with cirrhosis.3 ,8–15 Thus, in December 2012, the International Club of Ascites (ICA) organised a consensus development meeting in Venice, Italy, in order to reach a new definition of AKI in patients with cirrhosis. The discussion among the experts continued thereafter for 2 years, both online and through several meetings, between those experts who had different positions on crucial points on the subject. This paper reports the scientific evidence supporting the final proposal of a new approach to the diagnosis and treatment of this condition, on which the experts agreed.

Diagnostic criteria of AKI and their application in patients with cirrhosis

AKI is defined as an acute significant reduction in the glomerular filtration rate (GFR). sCr remains the most practical biomarker of renal function in patients with ARF (with or without cirrhosis). However, sCr as a biomarker of renal function has many limitations in clinical practice since it is influenced by bodyweight, race, age, and gender. The use of sCr in patients with cirrhosis is …

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  • Contributors Organisation of the meeting: PA; Analysis of data from the literature: PA, PG, FW, MB, TDB, AG, RM, RJ, SKS, SP, KM, SSL, FD, FS, PC, WRK, VA, GG; Drafting and writing the manuscript: PA, PG, FW, MB, SP, GG; Critical revision of data and manuscript revision: PA, PG, FW, MB, TDB, AG, RM, RJ, SKS, SP, KM, SSL, FD, FS, PC, VA, GG.

  • Funding PG: Research funding from Sequana Medical, Grifols SA; Consultancy Advisor to Ferring Pharmaceuticals; Competitive Public Grant Funding from: Fondos de Investigación Instituto de Salud CarlosIII (FIS12/0330) and Agència de Gestió d'Ajuts Universitaris i de Recerca (2014 SGR 708). MB: Consultant to CSL Behring GmbH, Baxter Healthcare SA; speaker to Behring GmbH, Baxter Healthcare SA, PPTA Europe. AG: Consultant to CSL Behring. RJ: Consultant to Ocera Therapeutics Inc, Conatus Pharmaceuticals Inc; Research grant from: Grifols Inc, Gambro AB, Sequana Medical AG, Norgine BV, Ocera Therapeutics Inc (the latter five companies are all involved in research collaboration); Speaker to Grifols Inc; Norgine BV; Inventors of Ornithine Phenylacetate licensed by UCL to Ocera Therapeutics; UCL spinout Yaqrit which will in-licence five of the following inventions in which R Jalan is the main inventor: YAQ001 nanoporous carbons for prevention of gut bacterial translocation, UCL liver dialysis device, DASIMAR biomarker for liver failure, Neutrophil for test: biomarker for predicting infection in decompensated cirrhotic patients, Urinary toll-like receptor 4: for differential diagnosis of renal dysfunction of cirrhosis. SSL: Consultant to Ikaria and Grifols. PC: Lecturer to Baxter Healthcare SA, Kedrion, Grifols. VA: Received grant and research support from Grifols.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Editors' note This article is being published jointly in Gut and Journal of Hepatology.

  • © 2015 BMJ Publishing Group Ltd, British Society of Gastroenterology and European Association for the Study of the Liver.