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World J Gastroenterol. Jun 28, 2012; 18(24): 3035-3049
Published online Jun 28, 2012. doi: 10.3748/wjg.v18.i24.3035
Kidneys in chronic liver diseases
Marek Hartleb, Krzysztof Gutkowski
Marek Hartleb, Krzysztof Gutkowski, Department of Gastroenterology and Hepatology, Medical University of Silesia, 40-752 Katowice, Poland
Author contributions: Hartleb M contributed to the study idea, study design, literature search, manuscript writing and final revision of the article; Gutkowski K contributed to the manuscript writing, literature search and final revision of the article.
Correspondence to: Marek Hartleb, Professor of Medicine, Head of the Department of Gastroenterology and Hepatology, Medical University of Silesia, ul. Medyków 14, 40-752 Katowice, Poland. mhartleb@sum.edu.pl
Telephone: +48-32-7894401 Fax: +48-32-7894402
Received: June 11, 2011
Revised: August 14, 2011
Accepted: March 9, 2012
Published online: June 28, 2012

Acute kidney injury (AKI), defined as an abrupt increase in the serum creatinine level by at least 0.3 mg/dL, occurs in about 20% of patients hospitalized for decompensating liver cirrhosis. Patients with cirrhosis are susceptible to developing AKI because of the progressive vasodilatory state, reduced effective blood volume and stimulation of vasoconstrictor hormones. The most common causes of AKI in cirrhosis are pre-renal azotemia, hepatorenal syndrome and acute tubular necrosis. Differential diagnosis is based on analysis of circumstances of AKI development, natriuresis, urine osmolality, response to withdrawal of diuretics and volume repletion, and rarely on renal biopsy. Chronic glomerulonephritis and obstructive uropathy are rare causes of azotemia in cirrhotic patients. AKI is one of the last events in the natural history of chronic liver disease, therefore, such patients should have an expedited referral for liver transplantation. Hepatorenal syndrome (HRS) is initiated by progressive portal hypertension, and may be prematurely triggered by bacterial infections, nonbacterial systemic inflammatory reactions, excessive diuresis, gastrointestinal hemorrhage, diarrhea or nephrotoxic agents. Each type of renal disease has a specific treatment approach ranging from repletion of the vascular system to renal replacement therapy. The treatment of choice in type 1 hepatorenal syndrome is a combination of vasoconstrictor with albumin infusion, which is effective in about 50% of patients. The second-line treatment of HRS involves a transjugular intrahepatic portosystemic shunt, renal vasoprotection or systems of artificial liver support.

Keywords: Acute kidney injury, Liver cirrhosis, Chronic renal failure, Chronic liver disease