Diagnosis and management of renal dysfunction in patients with cirrhosis

ABSTRACT

Introduction

Renal dysfunction commonly occurs in patients with cirrhosis and is typically associated with poor prognosis. Several pathophysiologic mechanisms are responsible for renal disease in these patients, prompt identification permits individualized management.

Areas covered

Pathophysiology, evaluation and differential diagnosis, management and prognosis of renal disease in patients with cirrhosis. Special focus on management of hepatorenal syndrome and indications for simultaneous liver-kidney transplantation.

Literature search methodology

a detailed literature search was performed using PubMed without date restrictions. Published guidelines and position papers were also used and cross-referenced to identify additional studies.

Expert opinion

The prognostic significance of renal dysfunction in patients with cirrhosis is highlighted by the inclusion of serum creatinine in the model for end-stage liver disease (MELD). Both acute and chronic renal dysfunction result in increased mortality in patients with cirrhosis, although there are marked differences related to the etiology of renal disease. Early recognition and prompt intervention determined by the most likely etiology are key in the management of these patients. Simultaneous liver-kidney transplantation improves patient survival compared to isolated liver transplantation in patients with cirrhosis and persistent renal impairment; however, selection of candidates must be judicious and individualized due to the ongoing shortage of donor kidneys.

KEYWORDS:

• Renal dysfunction
• acute kidney injury
• chronic kidney disease
• liver disease
• cirrhosis
• liver transplantation

Article highlights

• Renal dysfunction commonly occurs in patients with cirrhosis and is associated with worse prognosis and adverse outcomes.

• Criteria for diagnosing acute kidney injury (AKI) has been revised.

• Serum creatinine remains the most widely used clinical parameter for evaluation of renal function even though it has major limitations in patients with cirrhosis.

• Some liver diseases such as viral hepatitis and alcohol-related cirrhosis are associated with specific renal diseases that can lead to significant renal dysfunction.

• Hepatorenal syndrome-acute kidney injury (HRS-AKI) is associated with poor outcomes, medical management is centered on intravascular volume expansion and pharmacological vasoconstriction.

• Simultaneous liver-kidney transplantation is reserved for patients that meet specific criteria.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosure

One reviewer would like to declare that they are a honoraria speaker for BMS. They also receive travel reimbursement from Gilead, Abbvie and BMS, and financial support from W.L. Gore and associates, Medis, Pejcl Medizintechnik, and Cook medical.

All other reviewers on this manuscript have no relevant financial or other relationships to disclose.