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Bansal AD, Patel AA. Dialysis initiation for patients with decompensated cirrhosis when liver transplant is unlikely. Curr Opin Nephrol Hypertens 2024; 33:212-219. [PMID: 38038622 DOI: 10.1097/mnh.0000000000000959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to describe an approach that emphasizes shared decision-making for patients with decompensated cirrhosis and acute kidney injury when liver transplantation is either not an option, or unlikely to be an option. RECENT FINDINGS When acute kidney injury occurs on a background of decompensated cirrhosis, outcomes are generally poor. Providers can also be faced with prognostic uncertainty. A lack of guidance from nephrology and hepatology professional societies means that providers rely on expert opinion or institutional practice patterns. SUMMARY For patients who are unlikely to receive liver transplantation, the occurrence of acute kidney injury represents an opportunity for a goals of care conversation. In this article, we share strategies through which providers can incorporate more shared decision-making when caring for these patients. The approach involves creating prognostic consensus amongst multidisciplinary teams and then relying on skilled communicators to share the prognosis. Palliative care consultation can be useful when teams need assistance in the conversations.
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Affiliation(s)
- Amar D Bansal
- Renal Electrolyte Division, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Arpan A Patel
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California
- Greater Los Angeles Veterans Affairs Healthcare System, Gastroenterology, Hepatology and Parenteral Nutrition, Los Angeles
- VA Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), North Hills, California, USA
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Saly DL, Allegretti AS, Ufere NN. The SILK Collaborative: A Multidisciplinary Approach to Serious Illness Communication for Patients with Liver Failure and AKI. KIDNEY360 2024; 5:456-458. [PMID: 38323851 PMCID: PMC11000718 DOI: 10.34067/kid.0000000000000382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/29/2024] [Indexed: 02/08/2024]
Affiliation(s)
- Danielle L. Saly
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew S. Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Nneka N. Ufere
- Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Farooq U, Tarar ZI, El Alayli A, Kamal F, Niu C, Qureshi K. Analyzing the utility of renal replacement therapy to manage hepatorenal syndrome in alcoholic hepatitis without liver transplantation: a nationwide analysis. J Gastroenterol Hepatol 2024; 39:560-567. [PMID: 37953474 DOI: 10.1111/jgh.16388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/18/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Hepatorenal syndrome (HRS) frequently complicates alcoholic hepatitis (AH) and portends poor survival in this population. Published literature indicates mixed benefits from renal replacement therapy (RRT) for HRS refractory to medical management. Therefore, we sought to assess the utilization of RRT in AH and clinical outcomes at a national level. METHODS Using the International Classification of Diseases, Tenth Revision (ICD-10) codes, we identified adult patients with AH with a coexisting diagnosis of HRS from the National Readmission Database 2016 through 2019. Mortality, morbidity, and resource utilization were compared. We compared proportions using the Fisher exact test and computed adjusted P-values based on multivariate regression analysis. Analyses were performed using Stata, version 14.2, considering a two-sided P < 0.05 as statistically significant. RESULTS A total of 73 203 patients with AH were included in the analysis (mean age 46.2 years). A total of 3620 individuals had HRS diagnosis (5%), of which 14.7% (n: 532) underwent RRT. HRS patients receiving RRT had a higher mortality rate than those who did not (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI]: 1.3-2.6, P: 0.01), along with higher resource utilization. Only those patients with HRS who underwent liver transplantation (LT) experienced a mortality reduction (24.4% for those not receiving RRTs and 36.5% for those receiving RRT). CONCLUSIONS RRT is associated with higher mortality and morbidity when offered to patients with AH and HRS, who do not undergo LT. Therefore, our results suggest careful selection of AH patients when deciding to initiate RRT for HRS.
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Affiliation(s)
- Umer Farooq
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Zahid Ijaz Tarar
- Department of Internal Medicine, University of Missouri, Columbia, Missouri, USA
| | - Abdallah El Alayli
- Department of Internal Medicine, Saint Louis University, Saint Louis, Missouri, USA
| | - Faisal Kamal
- Department of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Chengu Niu
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Kamran Qureshi
- Division of Gastroenterology and Hepatology, Saint Louis University, Saint Louis, Missouri, USA
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Trautman CL, Khan M, Baker LW, Aslam N, Fitzpatrick P, Porter I, Mao M, Wadei H, Ball CT, Hickson LJ. Kidney Outcomes Following Utilization of Molecular Adsorbent Recirculating System. Kidney Int Rep 2023; 8:2100-2106. [PMID: 37850016 PMCID: PMC10577361 DOI: 10.1016/j.ekir.2023.07.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/24/2023] [Accepted: 07/31/2023] [Indexed: 10/19/2023] Open
Abstract
Introduction Molecular adsorbent recirculating system (MARS) is an extracorporeal system combining conventional veno-venous hemodiafiltration and adsorption to provide rescue support in fulminant hepatic failure. Acute kidney injury (AKI) is common in patients with hepatic failure warranting continuous kidney replacement therapy (CKRT). Our primary aim was to characterize a cohort of patients who received MARS therapy and examine kidney events given the current paucity of available data. Methods Patients initiating MARS in a tertiary care setting from January 2014 through December 2020 were assessed for treatment indications, transplantation, CKRT, kidney recovery, and death. Data was collected using the REDCAP software. Results A total of 49 patients (67% female; 75% White) received MARS therapy with 29 patients (59%) requiring concomitant CKRT. Hepatic encephalopathy (HE) was the most common indication for MARS initiation (55%). In-hospital mortality was 41% (12/29) among patients who received CKRT versus 10% (2/20) among those not requiring CKRT (relative risk [RR] 4.15, 95% confidence interval [CI] 1.04 to 16.52, P = 0.044); this persisted following adjustment for prespecified patient characteristics (all RR ≥ 3.76, all P ≤ 0.060). One-year mortality post-MARS initiation was high overall but highest among the CKRT group (59% [17/29] vs. 25% [5/20] unadjusted RR 2.92, 95% CI 1.08 to 7.94, P = 0.035). Liver transplant after MARS occurred in 41% of patients (20/49). After CKRT, 39% of patients (9/29) recovered kidney function prior to hospital discharge. Conclusions Patients requiring MARS frequently have AKI warranting the use of concomitant CKRT, which is associated with a high rate of in-hospital and 1-year mortality.
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Affiliation(s)
- Christopher L. Trautman
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
| | - Mahnoor Khan
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
| | - Lyle W. Baker
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
| | - Nabeel Aslam
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
| | - Peter Fitzpatrick
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
| | - Ivan Porter
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
| | - Michael Mao
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
| | - Hani Wadei
- Department of Transplantation; Mayo Clinic Jacksonville, Florida, USA
| | - Colleen T. Ball
- Division of Biomedical Statistics and Informatics, Mayo Clinic Jacksonville, Florida, USA
| | - LaTonya J. Hickson
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
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Velez JCQ, Wong F, Reddy KR, Sanyal AJ, Vargas HE, Curry MP, Gonzalez SA, Pappas SC, Jamil K. The Effect of Terlipressin on Renal Replacement Therapy in Patients with Hepatorenal Syndrome. KIDNEY360 2023; 4:1030-1038. [PMID: 37143199 PMCID: PMC10482068 DOI: 10.34067/kid.0000000000000132] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/21/2023] [Indexed: 05/06/2023]
Abstract
Key Points Hepatorenal syndrome type 1 (HRS-1) is an often fatal, but potentially reversible, kidney failure in patients with decompensated cirrhosis. Treatment with terlipressin in patients with HRS-1 is associated with a reduction in the need for RRT. Background Hepatorenal syndrome type 1 (HRS-1)—also known as hepatorenal syndrome-AKI (HRS-AKI)—is a rapidly progressing and usually fatal, but potentially reversible, kidney failure occurring in patients with decompensated cirrhosis. A large proportion of patients with HRS-1 require renal replacement therapy (RRT). Terlipressin demonstrated efficacy in reversing HRS and improving renal function in patients with HRS-1 in three phase III, randomized, clinical trials (RCTs; i.e. , OT-0401, REVERSE, and CONFIRM). However, these RCTs were not designed to evaluate the effect of terlipressin on the requirement of RRT. In this study, the effect of terlipressin on RRT requirements in the pooled phase III patient population was assessed. Methods For this retrospective analysis, data from patients who participated in the OT-0401, REVERSE, and CONFIRM studies were integrated in the largest-to-date randomized database (N =608). Results The need for RRT was significantly decreased in patients in the terlipressin group versus the placebo group by day 30 (28.1% versus 35.9%, respectively; P = 0.040) and day 60 (30.1% versus 37.9%, respectively; P = 0.045) in the pooled population and also postliver transplantation (LT) at day 60 (20.5% versus 40.3%, respectively; P = 0.008) and day 90 (25.3% versus 43.1%, respectively; P = 0.018). More patients were alive and RRT-free by day 90 in the overall population (36.9% versus 28.5%; P = 0.030) and among patients who received an LT (60.0% versus 39.7%; P = 0.010). Random assignment to receive terlipressin was an independent positive predictor of avoidance of RRT (P = 0.042); while higher baseline serum creatinine (sCr) level and Child-Pugh scores were negatively associated with RRT avoidance (P < 0.001 and P = 0.040, respectively). Conclusions Terlipressin decreased the requirement of RRT compared with placebo among patients with HRS-1, including those receiving LT. A lower sCr level at the beginning of therapy was associated with avoidance of RRT.
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Affiliation(s)
- Juan Carlos Q. Velez
- Department of Nephrology, Ochsner Health, New Orleans, Louisiana
- Ochsner Clinical School, The University of Queensland, Brisbane, Queensland, Australia
| | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - K. Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Arun J. Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Hugo E. Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona
| | - Michael P. Curry
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Stevan A. Gonzalez
- Department of Medicine, Baylor Scott & White All Saints Medical Center, Fort Worth, Texas
| | | | - Khurram Jamil
- Mallinckrodt Pharmaceuticals, Bridgewater, New Jersey
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Corona A, Dominguez M, Eti S. Palliative Care in Kidney and Liver Diseases. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:387-395. [PMID: 37657885 DOI: 10.1053/j.akdh.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 07/13/2023] [Accepted: 07/17/2023] [Indexed: 09/03/2023]
Abstract
The role of palliative care is to recognize patients with advanced illnesses who are at risk for poor outcomes and to alleviate their pain and suffering. Patients with both kidney and liver disease are a very vulnerable population due to the unique pathophysiologic relationship these two organs share, which often leads to an abbreviated life expectancy and a significant symptom burden. These patients face many challenges in their care. This article discusses the importance of prognostication for early palliative care referrals as well as the management of the two most common complaints patients with kidney and liver disease face: pain and ascites.
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Affiliation(s)
- Antonio Corona
- Albert Einstein College of Medicine at Montefiore Medical Center.
| | - Mary Dominguez
- Albert Einstein College of Medicine at Montefiore Medical Center
| | - Serife Eti
- Albert Einstein College of Medicine at Montefiore Medical Center
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Cooper KM, Colletta A, Moulton K, Ralto KM, Devuni D. Kidney disease in patients with chronic liver disease: Does sex matter? World J Clin Cases 2023; 11:3980-3992. [PMID: 37388789 PMCID: PMC10303604 DOI: 10.12998/wjcc.v11.i17.3980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/30/2023] [Accepted: 05/16/2023] [Indexed: 06/12/2023] Open
Abstract
Kidney disease in patients with liver disease is serious and increases mortality. Up to 50% of patients hospitalized experience an episode of acute kidney injury. In general, men with liver disease are thought to be at increased risk of kidney disease. However, this association should be considered with caution because most studies use creatinine-based inclusion criteria, which is negatively biased against women. In this review, we synthesize data on sex differences in kidney disease in patients with chronic liver disease in the clinical setting and discuss potential physiologic underpinnings.
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Affiliation(s)
- Katherine M Cooper
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Alessandro Colletta
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Kristen Moulton
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Kenneth M Ralto
- Department of Medicine, Division of Renal Medicine, UMass Chan Medical School, Worcester, MA 01665, United States
| | - Deepika Devuni
- Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01665, United States
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Rao S, Peterson CJ, Elmassry M, Songtanin B, Benjanuwattra J, Nugent K. Spontaneous peritoneal drainage following paracentesis in a hospitalized patient with resolution of type 1 hepatorenal syndrome. Am J Med Sci 2022; 364:789-795. [PMID: 35793730 DOI: 10.1016/j.amjms.2022.06.016] [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: 01/08/2022] [Revised: 03/21/2022] [Accepted: 06/28/2022] [Indexed: 01/25/2023]
Abstract
The hepatorenal syndrome develops in a small percentage of patients with advanced liver disease. The pathogenesis involves intravascular volume contraction secondary to pooling of blood in the splanchnic vessels, stimulation of the sympathetic nervous system and the renin-angiotensin-aldosterone pathway, and increased intra-abdominal pressure secondary to the formation of large volumes of ascitic fluid. The treatment options are limited, and liver transplant is the only definitive form of management. Here we suggest an alternative approach to treating hepatorenal syndrome based on the unexpected continuous peritoneal drainage in a 36-year-old man hospitalized with hepatic encephalopathy and hepatorenal syndrome. A total of 11.2 L ascitic fluid drained over 5 days from a paracentesis puncture site with marked improvement in renal function; the creatinine decreased from 3.3 mg/dL to 0.7 mg/dL and the BUN decreased from 42 mg/dL to 10 mg/dL. The discussion with this case report summarizes the pathogenesis, including the effect of intra-abdominal pressure, of the hepatorenal syndrome, outlines medical management, and makes a proposal for clinical study based on this case.
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Affiliation(s)
- Sanjana Rao
- School of Medicine, Texas Tech University Health Sciences CenterLubbock, TX, USA
| | | | - Marawan Elmassry
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Busara Songtanin
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Juthipong Benjanuwattra
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
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Abstract
AKI is commonly encountered in patients with decompensated cirrhosis, and it is associated with unfavorable outcomes. Among factors specific to cirrhosis, hepatorenal syndrome type 1, also referred to as hepatorenal syndrome-AKI, is the most salient and unique etiology. Patients with cirrhosis are vulnerable to traditional causes of AKI, such as prerenal azotemia, acute tubular injury, and acute interstitial nephritis. In addition, other less common etiologies of AKI specifically related to chronic liver disease should be considered, including abdominal compartment syndrome, cardiorenal processes linked to cirrhotic cardiomyopathy and portopulmonary hypertension, and cholemic nephropathy. Furthermore, certain types of GN can cause AKI in cirrhosis, such as IgA nephropathy or viral hepatitis related. Therefore, a comprehensive diagnostic approach is needed to evaluate patients with cirrhosis presenting with AKI. Management should be tailored to the specific underlying etiology. Albumin-based volume resuscitation is recommended in prerenal AKI. Acute tubular injury and acute interstitial nephritis are managed with supportive care, withdrawal of the offending agent, and, potentially, corticosteroids in acute interstitial nephritis. Short of liver transplantation, vasoconstrictor therapy is the primary treatment for hepatorenal syndrome type 1. Timing of initiation of vasoconstrictors, the rise in mean arterial pressure, and the degree of cholestasis are among the factors that determine vasoconstrictor responsiveness. Large-volume paracentesis and diuretics are indicated to relieve intra-abdominal hypertension and renal vein congestion. Direct-acting antivirals with or without immunosuppression are used to treat hepatitis B/C-associated GN. In summary, AKI in cirrhosis requires careful consideration of multiple potentially pathogenic factors and the implementation of targeted therapeutic interventions.
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Affiliation(s)
- Giuseppe Cullaro
- Department of Medicine, University of California, San Francisco, California
| | - Swetha Rani Kanduri
- Department of Nephrology, Ochsner Health, New Orleans, Louisiana
- Ochsner Clinical School, The University of Queensland, Brisbane, Queensland, Australia
| | - Juan Carlos Q. Velez
- Department of Nephrology, Ochsner Health, New Orleans, Louisiana
- Ochsner Clinical School, The University of Queensland, Brisbane, Queensland, Australia
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Kidney Replacement Therapy in Patients with Acute Liver Failure and End-Stage Cirrhosis Awaiting Liver Transplantation. Clin Liver Dis 2022; 26:245-253. [PMID: 35487608 DOI: 10.1016/j.cld.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Providing dialysis to patients with liver failure is challenging because of their tenuous hemodynamics and refractory ascites. With better machinery and increased availability, continuous kidney replacement therapy has been successfully delivered to acutely ill patients in liver failure over the past few decades. Intermittent hemodialysis continues to remain the modality of choice outside the intensive care unit and on occasion needs to be complemented with paracentesis. Peritoneal dialysis has not been widely used, but recent literature shows promising outcomes barring for publication bias. Albumin dialysis could be a lifesaving procedure for a carefully selected subgroup of patients with liver failure.
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