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©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
Published online Aug 6, 2014. doi: 10.4292/wjgpt.v5.i3.156
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/d | Urine osmolality > plasma osmolality |
Urine sodium < 10 mEq/L | Urine 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 criteria | Urine output | RIFLE criteria | |
Serum creatinine | (common to both AKIN and RIFLE) | Class | Serum 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 baseline | Less than 0.5 mL/kg per hour for more than 6 h | Risk | Increase in serum creatinine × 1.5 or GFR decrease > 25% |
Stage 2 | |||
Increased to more than 200% to 300% (≥ 2- to 2.9-fold) from baseline | Less than 0.5 mL/kg per hour for more than 12 h | Injury | Serum 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 RRT | Less than 0.3 mL/kg per hour for 24 h or anuria for 12 h | Failure | Serum 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% |
Loss | Persistent acute renal failure = complete loss of kidney function > 4 wk | ||
End-stage kidney disease | ESRD > 3 mo |
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 necrosis | Angeli et al[5] algorithm |
Acute kidney injury | Modified 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 disease | KDOQI[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 patients | RIFLE score[18,19] MBRS score[61,62] combining mean arterial pressure, bilirubin, respiratory failure and sepsis |
Candidates for liver transplantation | Exogenous filtration markers If there is suspicion for parenchymal disease and Glomerular filtration rate is between 30-60 mL/min consider renal biopsy |
Advanced cirrhosis | Cystatin C |
Difficulties in differentiation of acute tubular necrosis | NGAL |
All patients with cirrhosis in every stage of liver disease | Renal 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 ward | If 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 unit | Norepinephrine plus albumin |
Third line therapy | |
Patients who qualify for transplant | Consider liver or simultaneous liver kidney transplantation |
Give therapeutic bridges – Dialysis, transjugular intrahepatic portosystemic shunt | |
Patients who do not qualify for transplant | Continue the combination of terlipressin plus albumin |
Dialysis, TIPS |
Terlipressin is given as an intravenous bolus 1 to 2 mg every four to six hours | Albumin 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. |
- Citation: Pipili C, Cholongitas E. Renal dysfunction in patients with cirrhosis: Where do we stand? World J Gastrointest Pharmacol Ther 2014; 5(3): 156-168
- URL: https://www.wjgnet.com/2150-5349/full/v5/i3/156.htm
- DOI: https://dx.doi.org/10.4292/wjgpt.v5.i3.156