Outpatient mean arterial pressure: A potentially modifiable risk for acute kidney injury and death among cirrhosis patients.

BACKGROUND: Mean arterial blood pressure (MAP), which decreases as portal hypertension progresses, may be a modifiable risk factor among cirrhosis patients.

METHODS: We included adults enrolled in the FrAILT study. We completed latent class trajectory analyses (LCTA) to define MAP trajectories. We completed time-dependent Cox-regression analyses to test the association between outpatient MAP and 3 cirrhosis-related outcomes: 1) Stage 2 acute kidney injury (AKI), defined as a ≥200% increase in serum creatinine from baseline; 2) a 5-point increase in the MELDNa score, defined as the incidence of increase from initial MELDNa; 3) waitlist mortality (WLM), defined as death on the WL. For each outcome, we defined MAP cutpoints by determining the maximally selected Log-rank statistic after univariable Cox-regression analyses.

RESULTS: Among the 1,786 patients included in this analysis, our LCTA identified 3-specific outpatient MAP trajectories: "stable-low", "stable-high", and "increasing-to-decreasing". However, >80% of patients were in a "stable-low" trajectory. We found in adjusted analyses that outpatient MAP was associated with each of our outcomes: Stage 2 AKI (adjusted hazard ratio [aHR]0.88 per 10 mmHg increase in MAP[95CI 0.79-0.99]); 5-point increase in MELDNa (aHR0.91[95CI 0.86-0.96]; WLM (aHR0.89[95CI 0.81-0.96]). For each outcome, we found that an outpatient MAP of 82 mmHg was most associated with outcomes (p<0.05 for all).

DISCUSSION: Our study informs the association between outpatient MAP and cirrhosis-related outcomes. These findings, coupled with the identification of specific thresholds, lays the foundation for the trial of targeted outpatient MAP modulation in cirrhosis patients.