Review
Copyright ©2014 Baishideng Publishing Group Inc.
World J Gastrointest Pharmacol Ther. Aug 6, 2014; 5(3): 156-168
Published online Aug 6, 2014. doi: 10.4292/wjgpt.v5.i3.156
Table 1 International Ascites Club definition and diagnostic criteria for hepatorenal syndrome[7,116]
1996 criteria
Major criteria
Chronic or acute liver disease with advanced hepatic failure and portal hypertension
Serum creatinine > 1.5 mg/dL or 24-h creatinine clearance of < 40 mL/min
Absence of shock, ongoing bacterial infection, and current or recent treatment with nephrotoxic drugs. Absence of gastrointestinal fluid losses (repeated vomiting or intense diarrhea) or renal fluid losses
No sustained improvement in renal function defined as a decrease in serum creatinine to < 1.5 mg/dL or increase in creatinine clearance to 40 mL/min or more following diuretic withdrawal and expansion of plasma volume with 1.5 L of isotonic saline
Proteinuria < 500 mg/dL and no ultrasonographic evidence of obstructive uropathy or parenchymal renal disease
Minor criteria
Urine volume < 500 mL/dUrine osmolality > plasma osmolality
Urine sodium < 10 mEq/LUrine red blood cells < 50 per high power field
Table 2 Acute kidney injury network and risk, injury, failure, loss, and end stage criteria for the diagnosis of acute kidney injury[117]
AKIN criteriaUrine outputRIFLE criteria
Serum creatinine(common to both AKIN and RIFLE)ClassSerum creatinine or GFR
Stage 1
Increase of more than or equal to 0.3 mg/dL (≥ 26.5 μmol/L) or increase to more than or equal to 150% to 199% (1.5- to 1.9-fold) from baselineLess than 0.5 mL/kg per hour for more than 6 hRiskIncrease in serum creatinine × 1.5 or GFR decrease > 25%
Stage 2
Increased to more than 200% to 300% (≥ 2- to 2.9-fold) from baselineLess than 0.5 mL/kg per hour for more than 12 hInjurySerum creatinine × 2 or GFR decreased > 50%
Stage 3
Increased to more than 300% (≥ 3-fold) from baseline, or more than or equal to 4.0 mg/dL (≥ 354 μmol/L) with an acute increase of at least 0.5 mg/dL (44 μmol/L) or on RRTLess than 0.3 mL/kg per hour for 24 h or anuria for 12 hFailureSerum creatinine × 3, or serum creatinine > 4 mg/dL (> 354 μmol/L) with an acute rise > 0.5 mg/dL (> 44 μmol/L) or GFR decreased > 75%
LossPersistent acute renal failure = complete loss of kidney function > 4 wk
End-stage kidney diseaseESRD > 3 mo
Table 3 Formulas for estimating the glomerular filtration rate: modified diet in renal disease-4, modified diet in renal disease-6, chronic kidney disease epidemiology collaboration (mL/min per 1.73 m2)[118-120]
MDRD-4 formula (1)186 × [creatinine (mg/dL)] -1.154 × [age (yr)] 0.203 × (0.742 if patient is female) × (1.21 if patient is black)
MDRD-6 formula (2)170 × sCr (mg/dL)-0.999 × age-0.176 × 1.180 (if black) × 0.762 (if female) × serum urea nitrogen-0.170 × albumin 0.138
CKD-EPI equation (3)141 × min (sCr/κ, 1)α× max (sCr/κ, 1)-1.209 × 0.993 Age × 1.018 (if female) × 1.159 (if black)
Table 4 Recomendations for renal function evaluation in subgroups of patients with cirrhosis
Differentiate prerenal kidney disease, hepatorenal syndrome and acute tubular necrosisAngeli et al[5] algorithm
Acute kidney injuryModified cirrhosis–acute kidney injury classification sCr increase ≥ 0.3 mg/dL (≥ 26.4 μmol/L) or more than 150% (1.5 fold from baseline) within 48 h from the first measurement[12]
Chronic kidney diseaseKDOQI[49] guidelines Glomerular filtration rate below 60 mL/min for more than three months, calculated using the modified diet in renal disease-6 formula chronic kidney disease epidemiology collaboration Cys C-Cr equation[51]
Critically ill cirrhotic patientsRIFLE score[18,19] MBRS score[61,62] combining mean arterial pressure, bilirubin, respiratory failure and sepsis
Candidates for liver transplantationExogenous filtration markers If there is suspicion for parenchymal disease and Glomerular filtration rate is between 30-60 mL/min consider renal biopsy
Advanced cirrhosisCystatin C
Difficulties in differentiation of acute tubular necrosisNGAL
All patients with cirrhosis in every stage of liver diseaseRenal resistive index estimation by renal duplex doppler ultrasound
Table 5 Recomendations for management of patients with cirrhosis
First line therapy
Recognize and withdraw all causes of acute kidney disease
Resolve primary liver disease
Encounter hypoalbuminemia with albumin infusion and tension ascites with repeated paracentesis plus albumin
Have a high level of suspicion and treat spontaneous bacterial peritonitis
Be vigilant and have into close monitoring patients win acute kidney injury network stage 1 and sCr > 1.5 mg/dL (133 μmol/L) or initial acute kidney injury network stage > 1
If there is no improvement within 2 d, proceed to specific treatment measures
Second line therapy
Patients hospitalized at the wardIf the diagnosis of hepatorenal syndrome has been placed:
Give albumin and terlipressin in continuous infusion
If there is improvement within 4 d continue with oral midrodrine
When terlipressin is unavailable:
Give midrodrine plus octreotide plus albumin
Patients admitted to intensive care unitNorepinephrine plus albumin
Third line therapy
Patients who qualify for transplantConsider liver or simultaneous liver kidney transplantation
Give therapeutic bridges – Dialysis, transjugular intrahepatic portosystemic shunt
Patients who do not qualify for transplantContinue the combination of terlipressin plus albumin
Dialysis, TIPS
Table 6 Scheme for terlipressin and albumin administration[5,97]
Terlipressin is given as an intravenous bolus 1 to 2 mg every four to six hoursAlbumin is given for two days as an intravenous bolus 1 g/kg per day (100 g maximum) followed by 25 to 50 g /d until terlipressin therapy is discontinued
Table 7 Published guidelines on selection criteria for simultaneous liver-kidney transplantation
Davis et al[121], 2007
Patients with CKD with CrCl (preferentially iothalamate) of ≤ 30 mL/min for > 3 mo
Patients with AKI and/or HRS on dialysis for ≥ 6 wk
Patients with prolonged AKI with kidney biopsy showing fixed renal damage
SLK was not recommended in patients with AKI not requiring dialysis
Eason et al[122], 2008
Patients with CKD with GFR ≤ 30 mL/min > 3 mo
Patients with AKI/HRS with sCr ≥ 2 mg/dL and on dialysis ≥ 8 wk
Patients with evidence of CKD and kidney biopsy with > 30% GS or 30% fibrosis
Other criteria that was recommended to be considered: Presence of co-morbidities: Diabetes, Hypertension, age > 65 yr, renal size and duration of sCr > 2 mg/dL
Nadim et al[123], 2012
Persistent AKI ≥ 4 wk with one of the following:
Increase Scr ≥ 3-fold from baseline or on dialysis
GFR ≤ 35 mL/min (MDRD-6) or ≤ 25 mL/min (iothalamate)
CKD ≥ 3 mo with one of the following:
eGFR ≤ 40 mL/min (MDRD-6) or ≤ 30 mL/min (iothalamate)
Proteinuria ≥ 2 g/d
Kidney biopsy showing > 30% GS or > 30% interstitial fibrosis
Note: Higher GFR threshold with MDRD-6 was to account for the approximate 30%- 40% overestimation that has been described when compared to iothalamate.