Initial Resuscitation for Acute Kidney Injury in Cirrhosis

This randomized, open-label, pilot feasibility trial will assess a volume assessment guidance algorithm (VAGA) in patients with AKI and cirrhosis. Eligible patients must have AKI and decompensated cirrhosis. In addition to assessing the adherence to the suggested guidance, this study will measure the effect of the study intervention on grams of albumin given, clinical efficacy outcomes (AKI response rates, survival, RRT status, transplant status), and safety.

Patients who meet eligibility criteria will be randomized 1:1 where the treating clinicians will receive a one-time recommendation for volume resuscitation using the VAGA or standard of care IV albumin repletion (1 g/kg/day for two days). Both groups will be followed with assessments at 48 hours after randomization, hospital discharge, and 90-days after randomization.

The primary efficacy outcome, grams of albumin, will be measured at 48 hours after randomization. Primary secondary efficacy outcomes (grams of albumin, AKI response) will be assessed at time of hospital discharge. If a patient undergoes liver transplantation or initiation of RRT during the admission, this will serve as a censoring date for these outcomes, and relevant data will be collected at the time of the first of these events.

The primary feasibility outcome is adherence to the suggested guidance, assessed at 48 hours after randomization. The VAGA group will receive one of three potential clinical recommendations: (a) no further volume resuscitation, (b) resuscitation with crystalloid, or (c) resuscitation with colloid.

This study will prospectively enroll approximately 50 adult patients at a single center.

Inclusion criteria

• Adult age 18 years or greater
• Signed informed consent form (ICF) by any subject capable of giving consent, or, when the subject is not capable of giving consent, by their legally authorized representatives prior to initiation of any study procedures.
• Admitted to the hospital
• Diagnosis of decompensated cirrhosis (either prior to admission or new diagnosis on admission).
• Presence of acute kidney injury (AKI) as defined by International Club of Ascites (ICA) criteria, defined as SCr increase of ≥0.3 mg/dL within 48 hours or ≥50% increase from baseline which is known or presumed to have occurred within the prior 7 days.

Exclusion criteria

• Requiring >2 liters (L) supplemental oxygen at the time of screening.
• In shock requiring vasopressors (vasoconstrictors for the treatment of AKI such as terlipressin, midodrine, and octreotide are allowed).
• Allergy or other contraindication to IV albumin administration.
• Death, liver transplant, or renal replacement therapy (RRT) expected within 48 hours.
• Patient and/or legally authorized representative unable to provide informed consent.
• Hepatic encephalopathy grade 3 or 4 at the time of screening.
• Already received >200 g albumin during admission at the time of screening.
• Severe, active bleeding requiring 3 or more units of red blood cell transfusion in the 48 hours prior to screening.
• Admission to the intensive care unit at the time of screening.
• Mechanical ventilation at the time of screening.
• Presence of New York Heart Association (NYHA) class 3-4 symptoms of congestive heart failure at the time of screening.
• History of prior liver or kidney transplant.
• Pregnant or nursing status
• Any condition, in the opinion of the investigator, that could confound or interfere with the safe completion of study activities.