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Kidney Week

Abstract: FR-PO004

Assessment of Utility of Urine Sediment Microscopy in Hepatorenal AKI

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical, Outcomes, and Trials

Authors

  • Rivera, Maria Soledad, Ochsner Clinic Foundation, New Orleans, Louisiana, United States
  • Alghamdi, Ayman M., Ochsner Clinic Foundation, New Orleans, Louisiana, United States
  • Velez, Juan Carlos Q., Ochsner Clinic Foundation, New Orleans, Louisiana, United States
Background


Microscopic examination of the urinary sediment (MicrExUrSed) is a useful diagnostic tool in acute kidney injury (AKI). However, its performance has not been examined in AKI in patients with end-stage liver disease (ESLD). Hepatorenal syndrome type 1 (HRS-1), a type of AKI in ESLD, is difficult to diagnose despite the existence of the International Club of Ascites (ICA) criteria. We hypothesized that MicrExUrSed improves accuracy of diagnosis of acute tubular injury (ATI) in ESLD patients with AKI.

Methods

MicrExUrSed was performed in patients with AKI stage ≥ 2 with or without ESLD over a 6-month period. HRS-1 was defined by the ICA criteria. Urine Na <20 mEq/L, urine volume <500 ml, mean arterial pressure <75 mmHg and serum Na <135 mEq/L were supportive criteria. Definite HRS-1 was defined as: ICA + supportive criteria were met. Possible HRS was defined as: only ICA criteria were met. No HRS was defined as: ≥1 ICA criteria was not met. Urinary cast scores (based on Chawla et al and Perazella et al) were assigned to each specimen. Chawla scores (CS) 3-4 and Perazella scores (PS) 2-3 were deemed consistent with ATI and not HRS-1.

Results


Distribution of casts (>25% lpf with ≥1 cast) differed between the ESLD (n=35) and non-ESLD (n=44) groups. Hyaline casts (HC), renal tubular epithelial cell casts (RTECC) and waxy casts (WC) were identified more often in ESLD compared to non-ESLD [57 vs 29% (p<0.05); 26 vs 5% (p<0.01) and 20 vs 5% (p<0.05) for HC, RTECC and WC], but not granular casts [43 vs 61%]. In the ESLD group, total bilirubin was significantly higher for those with RTECC [35.9 vs. 6.4 mg/dL (p<0.0001)] suggesting pathogenesis of bile cast tubulopathy. A diagnosis of Definite HRS-1 was assigned to 6 (17%), Possible HRS-1 to 14 (40%) and No HRS-1 to 15 (43%) patients. Addition of MicrExUrSed changed the diagnosis in 11 (31%) patients: Definite HRS-1 was changed to No HRS-1 in 2 and Possible HRS-1 was changed to No HRS-1 in 9, changing the final No HRS-1 count to 26 (74%) and HRS-1 to 9 (26%). Nonetheless, vasoconstrictor therapy to treat HRS-1 was given to 23 (66%) patients.

Conclusion


MicrExUrSed can aid in the diagnosis of AKI in ESLD by identifying those with evidence of ATI, i.e., not consistent with HRS-1, with potential implications on the use of vasoconstrictor therapy and/or dialysis decisions.