Dual Organ Duel: The Hepatorenal Axis

Recent developments in our understanding of the pathogenesis of kidney disease in the setting of liver failure have highlighted that kidney injury, rather than occurring in isolation, is a marker of systemic disease and poor prognosis. The differential diagnosis of kidney disease associated with liver failure is broader than formerly described and new biopsy data, along with better acute kidney injury classification tools, have increased appreciation for distinct pathophysiological mechanisms. Evidence suggests that acute kidney injury contributes to worsening hepatic failure by directly injuring hepatic cells and by imposing restrictions on therapeutic strategies for portal hypertension. Furthermore, kidney injury limits the use of various therapeutic agents and increases their toxicity due to altered pharmacodynamics. A greater appreciation of CKD in this population is also overdue because management decisions are affected and increased vigilance may avoid further kidney injury. A multidisciplinary approach to kidney injury in the setting of liver failure will enable targeted therapeutic strategies that are safe and effective and serve to guide further research, while limiting clinical potential for harm. Finally, new hepatitis C antiviral therapies promise to change the landscape of liver failure, and a discussion of kidney risk factors and antiviral therapy of patients with kidney disease and hepatitis C is worthwhile.