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Ozturk NB, Dinc EJ, Swami A, Gurakar A. Acute Kidney Injury and Hepatorenal Syndrome in Patients with Cirrhosis. J Clin Med 2023; 13:199. [PMID: 38202206 PMCID: PMC10779857 DOI: 10.3390/jcm13010199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/25/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024] Open
Abstract
Acute kidney injury (AKI) is common in hospitalized patients with cirrhosis. Hepatorenal syndrome (HRS) is a type of AKI known as HRS-AKI. It is a severe complication of cirrhosis with high morbidity and mortality. While certain vasoconstrictor medications have been shown to improve HRS-AKI, no clear transplant-free survival benefit has been reported with medical therapies. Patients with HRS-AKI should be considered for urgent liver transplantation evaluation. In this review, we discuss the most recent updates on the definition, diagnosis, and management of AKI in cirrhosis, with special a emphasis on HRS.
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Affiliation(s)
- Nazli Begum Ozturk
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI 48073, USA
| | - Ece Janet Dinc
- School of Medicine, Baskent University, 06790 Ankara, Turkey
| | - Abhishek Swami
- Division of Nephrology, Beaumont Hospital, Royal Oak, MI 48073, USA
| | - Ahmet Gurakar
- Division of Gastroenterology and Hepatology, Johns Hopkins University Hospital, Baltimore, MD 21287, USA
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Calleri A, Alessandria C. Renal damage in Hepatorenal Syndrome: A still unsolved issue. Clin Res Hepatol Gastroenterol 2023; 47:102178. [PMID: 37453679 DOI: 10.1016/j.clinre.2023.102178] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/02/2023] [Accepted: 07/12/2023] [Indexed: 07/18/2023]
Abstract
Acute kidney injury (AKI) is a common complication of cirrhosis, burdened by high morbidity and mortality rates and progression to chronic kidney disease. Hepatorenal syndrome (HRS) is a peculiar type of functional AKI observed in cirrhotic patients with ascites. HRS diagnosis is still clinical, once pre-renal azotemia and intrinsic kidney damage have been excluded by applying well-established and internationally adopted criteria. HRS is considered reversible because of the absence of intrinsic renal damage. However, HRS reversibility has been questioned, due to the lack of response to treatment with vasoconstrictors plus albumin in a relevant percentage of patients and to the persistence of renal dysfunction in HRS patients who underwent liver transplantation (LT). Indeed, LT is the only ultimate treatment, as it solves both liver failure and portal hypertension. Thus, the presence of renal damage in HRS can be hypothesized. In this scenario, neutrophil gelatinase-associated lipocalin (NGAL), one of the most promising biomarkers, may help in characterizing the type of renal injury, distinguishing between HRS and acute tubular necrosis. This review gathers the available evidence in favor and against the presence of structural lesions in HRS in terms of either renal histology and urinary biomarkers with a particular focus on NGAL. The ability to properly characterize which component of renal dysfunction prevails - functional rather than structural - entails a relevant clinical impact for the treatment of these patients, both in terms of medical therapy and liver vs. combined liver-kidney transplantation.
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Affiliation(s)
- Alberto Calleri
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Italy.
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Yoo JJ, Park MY, Kim SG. Acute kidney injury in patients with acute-on-chronic liver failure: clinical significance and management. Kidney Res Clin Pract 2023; 42:286-297. [PMID: 37313610 DOI: 10.23876/j.krcp.22.264] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/06/2023] [Indexed: 06/15/2023] Open
Abstract
Acute-on-chronic-liver failure (ACLF) refers to a phenomenon in which patients with chronic liver disease develop multiple organ failure due to acute exacerbation of underlying liver disease. More than 10 definitions of ACLF are extant around the world, and there is lack of consensus on whether extrahepatic organ failure is a main component or a consequence of ACLF. Asian and European consortiums have their own definitions of ACLF. The Asian Pacific Association for the Study of the Liver ACLF Research Consortium does not consider kidney failure as a diagnostic criterion for ACLF. Meanwhile, the European Association for the Study of the Liver Chronic Liver Failure and the North American Consortium for the Study of End-stage Liver Disease do consider kidney failure as an important factor in diagnosing and assessing the severity of ACLF. When kidney failure occurs in ACLF patients, treatment varies depending on the presence and stage of acute kidney injury (AKI). In general, the diagnosis of AKI in cirrhotic patients is based on the International Club of Ascites criteria: an increase of 0.3 mg/dL or more within 48 hours or a serum creatinine increase of 50% or more within one week. This study underscores the importance of kidney failure or AKI in patients with ACLF by reviewing its pathophysiology, prevention methods, and treatment approaches.
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Affiliation(s)
- Jeong-Ju Yoo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University School of Medicine, Bucheon, Republic of Korea
| | - Moo Yong Park
- Division of Nephrology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University School of Medicine, Bucheon, Republic of Korea
| | - Sang Gyune Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University School of Medicine, Bucheon, Republic of Korea
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Seshadri A, Appelbaum R, Carmichael SP, Cuschieri J, Hoth J, Kaups KL, Kodadek L, Kutcher ME, Pathak A, Rappold J, Rudnick SR, Michetti CP. Management of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open 2022; 7:e000936. [PMID: 35991906 PMCID: PMC9345092 DOI: 10.1136/tsaco-2022-000936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/20/2022] [Indexed: 11/04/2022] Open
Abstract
Management of decompensated cirrhosis (DC) can be challenging for the surgical intensivist. Management of DC is often complicated by ascites, coagulopathy, hepatic encephalopathy, gastrointestinal bleeding, hepatorenal syndrome, and difficulty assessing volume status. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews practical clinical questions about the critical care management of patients with DC to facilitate best practices by the bedside provider.
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Affiliation(s)
- Anupamaa Seshadri
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rachel Appelbaum
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Samuel P Carmichael
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Joseph Cuschieri
- Department of Surgery, San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Jason Hoth
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Krista L Kaups
- Department of Surgery, UCSF Fresno, Fresno, California, USA
| | - Lisa Kodadek
- Surgery, Yale University School of Medicine, New Haven, Connecticut, USA,Department of Surgery, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Matthew E Kutcher
- Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Abhijit Pathak
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joseph Rappold
- Department of Surgery, Maine Medical Center, Portland, Oregon, USA
| | - Sean R Rudnick
- Department of Gastroenterology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
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Januszko-Giergielewicz B, Kobryń A, Donderski R, Trzcinska J, Theda-Pawelska J, Romaszko-Wojtowicz A, Shevchuk A, Słupski M. Hepatorenal Syndrome and Other Post-Liver Transplantation Complications: Case Studies and Literature Review. Transplant Proc 2022; 54:1029-1036. [PMID: 35760626 DOI: 10.1016/j.transproceed.2022.03.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/05/2022] [Accepted: 03/14/2022] [Indexed: 01/09/2023]
Abstract
Hepatorenal syndrome (HRS) was originally defined as a renal dysfunction caused by a decreased renal perfusion due to hemodynamic disturbances in the arterial circulation and an excessive activity of endogenous vasoactive systems in the course of cirrhosis. Considering the latest research, this syndrome may have a more complex pathomechanism. Equally often as in cirrhosis, HRS develops after orthotopic liver transplantation (OLTx) and worsens the prognosis significantly increasing mortality rates in this patient population. The prevalence of renal complications after OLTx and their negative prognostic impact on the survival of both the graft and the recipient prompted the authors of this work to analyze in detail 2 cases of HRS after OLTx to indicate the multiplicity of factors contributing to the pathophysiology of this syndrome. Attention was paid to risk factors for HRS found in the anamnesis before OLTx, especially a pre-existing renal dysfunction. In both cases early post-OLTx complications associated with the transplantation procedure were described: destabilization of the circulatory system, transfusions of blood products, prolonged stay at an intensive care unit, and necessity of introducing continuous renal replacement therapy. In the later period after the OLTx, infections (bacterial, fungal, viral) and drug nephrotoxicity, including the activity of immunosuppressants (tacrolimus), contributed primarily to the renal function impairment.
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Affiliation(s)
- Beata Januszko-Giergielewicz
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland.
| | - Andrzej Kobryń
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
| | - Rafał Donderski
- Department of Nephrology, Internal Diseases and Hypertention, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
| | - Joanna Trzcinska
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
| | - Joanna Theda-Pawelska
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
| | - Anna Romaszko-Wojtowicz
- Department of Pulmonology, Faculty of Public Health, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Poland
| | - Andii Shevchuk
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
| | - Maciej Słupski
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
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Habas E, Ibrahim AR, Moursi MO, Shraim BA, Elgamal ME, Elzouki AN. Update on hepatorenal Syndrome: Definition, Pathogenesis, and management. Arab J Gastroenterol 2022; 23:125-133. [PMID: 35473682 DOI: 10.1016/j.ajg.2022.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 12/25/2021] [Accepted: 01/27/2022] [Indexed: 12/18/2022]
Abstract
Hepatorenal syndrome (HRS) is acute kidney injury (AKI) that occurs without evidence of structural abnormalities in the kidneys in patients with liver disease. It is thought to be due to splanchnic vasculature dilatation that is associated with intense increase of renal arteries' tone, leading to renal cortex ischemia and AKI. Nitric oxide, endotoxins, neurohormonal changes, bacterial infection, high serum bilirubin and bile acids are examples for factors contributing to HRS development. Nevertheless, other unknown factors may have role in HRS pathophysiology. Hence, further discussion and research are needed to clearly understand HRS. Plasma volume restoration and vasoconstrictors are the cornerstone of HRS treatment. Others such as octreotide, noradrenaline, infection control, systemic inflammatory response prevention, shunting, and renal replacement therapy are currently used to manage HRS. Liver or combined liver and kidney transplantation is currently the ultimate cure for HRS. This review was written to help in better understanding the pathogenesis, diagnosis, and treatment options for HRS.
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Affiliation(s)
- Elmukhtar Habas
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ayman R Ibrahim
- College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Moaz O Moursi
- College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Bara A Shraim
- College of Medicine, QU Health, Qatar University, Doha, Qatar
| | | | - Abdel-Naser Elzouki
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; College of Medicine, QU Health, Qatar University, Doha, Qatar; Weill Cornell Medical College, Qatar.
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