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Renal dysfunction and cirrhosis.

François Durand1, Jody C Olson, Mitra K Nadim

  • 1aHepatology & Liver Intensive Care, Hospital Beaujon, Clichy, University Paris Diderot, Paris, France bDivisions of Critical Care Medicine and Hepatology, University of Kansas Medical Center, Kansas City, Kansas cDivision of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, California, USA.

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Early recognition of hepatorenal syndrome (HRS) in cirrhosis is crucial. New definitions and biomarkers aid in differentiating HRS from acute tubular necrosis (ATN), guiding timely treatment and transplantation decisions.

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Area of Science:

  • Nephrology
  • Hepatology
  • Transplantation

Background:

  • Hepatorenal syndrome (HRS) is a complex complication of cirrhosis.
  • Acute kidney injury (AKI) in cirrhosis requires precise diagnosis for effective management.
  • Current diagnostic criteria for AKI in cirrhosis may need refinement.

Purpose of the Study:

  • To review the redefined criteria for AKI in cirrhosis.
  • To discuss novel biomarkers for early detection of kidney injury.
  • To evaluate current therapeutic strategies for HRS, including vasopressors and transplantation.

Main Methods:

  • Literature review of recent studies on AKI in cirrhosis.
  • Analysis of new biomarkers such as NGAL and IL-18.
  • Evaluation of data on vasopressor use and outcomes in HRS.
  • Review of criteria for simultaneous liver and kidney transplantation (SLKT).

Main Results:

  • Urine output, previously excluded, shows prognostic value in AKI.
  • Biomarkers like NGAL and IL-18 may help identify acute tubular necrosis (ATN), but require standardized cut-offs.
  • Vasopressors combined with albumin are the primary treatment for HRS; continuous terlipressin infusion offers a better safety profile.
  • SLKT is indicated when native kidney recovery is improbable, particularly with prolonged renal replacement therapy (RRT) or low GFR.

Conclusions:

  • Revised AKI definitions and new biomarkers can improve early differentiation between HRS and ATN.
  • Reconsidering urine output in AKI definitions is warranted.
  • A trial of RRT is justifiable for patients not initially eligible for transplantation.
  • SLKT should be considered when post-transplant renal recovery is unlikely.