Management of acute kidney injury in liver disease

Acute deterioration in kidney function often occurs in patients with acute and chronic liver disease admitted to hospital. The true incidence of acute kidney injury (AKI) is unknown due to the difficulty in accurately measuring kidney function in patients with liver failure, and the lack of a consensus definition of AKI. There is a current consensus definition of hepatorenal syndrome (HRS), but in current clinical practice, volume-unresponsive AKI or acute tubular necrosis are much more common causes of AKI in patients with liver disease. Due to arterial vasodilatation and compensatory neuroendocrine activation, these patients are more prone to AKI due to a combination of changes in renal autoregulation and a sudden reduction in effective plasma volume or hypotension. The key management strategy is to prevent the development of HRS, by avoiding nephrotoxins, and preventing infective complications, and maintaining an effective circulating volume. In patients with HRS, treatment centres around daily plasma volume expansion, typically with albumin, in combination with vasopressors, typically vasopressin analogues, such as terlipressin, or noradrenaline. If renal function does not recover, then renal support with dialysis may be appropriate.