Pipili C, Cholongitas E. Renal dysfunction in patients with cirrhosis: Where do we stand? World J Gastrointest Pharmacol Ther 2014; 5(3): 156-168 [PMID: 25133044 DOI: 10.4292/wjgpt.v5.i3.156]
Corresponding Author of This Article
Evangelos Cholongitas, Senior Lecturer of Internal Medicine, 4th Department of Internal Medicine, Medical School of Aristotle University, Hippokration General Hospital of Thessaloniki, 49, Konstantinopoleos Street, 54642 Thessaloniki, Greece. cholongitas@yahoo.gr
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Review
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
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/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
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)
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
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 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
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
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