Development of a clinical risk score for early prediction of hepatorenal syndrome in hospitalized cirrhotic patients with acute kidney injury: a retrospective study from India

Background: Hepatorenal syndrome–acute kidney injury (HRS-AKI) is a severe and potentially reversible complication of advanced cirrhosis associated with high short-term mortality. Early identification of patients at risk remains challenging and currently available prognostic models are not specifically designed to predict the onset of HRS-AKI. Therefore, early risk stratification using simple clinical parameters is essential to facilitate timely therapeutic interventions. This study aimed to develop and internally validate a simple clinical risk score for early prediction of HRS-AKI among hospitalized cirrhotic patients presenting with acute kidney injury (AKI). Methods: This retrospective cohort study included 260 hospitalized patients with liver cirrhosis and AKI admitted between February 2022 and August 2023. Demographic, clinical and laboratory parameters recorded at admission were analyzed. Independent predictors of HRS-AKI were identified using multivariable logistic regression analysis. A weighted clinical risk score was derived from the regression coefficients and internally validated using bootstrapping techniques. The discriminatory ability of the model was compared with established prognostic scores including MELD, MELD-Na and CLIF-C ACLF. Results: HRS-AKI developed in 80 patients (30.7%). Independent predictors included mean arterial pressure<80 mmHg, serum sodium <130 mmol/l, serum bilirubin ≥6 mg/dl, serum albumin ≤2.8 g/dl and presence of infection at admission (all p<0.01). The derived clinical risk score (range 0–12) demonstrated good discrimination (AUC 0.83; 95% CI 0.78–0.87) and calibration (Hosmer–Lemeshow p=0.46). The incidence of HRS-AKI increased across low- (0–3), moderate- (4–7) and high-risk (≥8) groups (9%, 29% and 67%, respectively, p<0.001). The model outperformed MELD, MELD-Na and CLIF-C ACLF scores. Conclusions: A simple bedside clinical risk score using routinely available parameters can accurately predict HRS-AKI in hospitalized cirrhotic patients and may aid early risk stratification and timely management to improve renal and survival outcomes.