From the Guidelines
Hemodialysis is not a recommended treatment for cirrhosis patients without liver transplantation due to dismal survival rates, as reported in a study where no survivors were found out of 25 patients 1. When considering hemodialysis for cirrhosis patients, it is crucial to prioritize their complex pathophysiology and the potential risks associated with the treatment.
- Hemodialysis is frequently used to control azotemia and maintain electrolyte balance before liver transplantation, but it is not a viable long-term solution for patients with cirrhosis.
- The use of hemodialysis in cirrhosis patients is often complicated by hypotension, which can be mitigated by using continuous venovenous hemofiltration, but this requires continuous involvement of a dialysis nurse 1.
- Liver transplantation is considered an effective treatment for hepatorenal syndrome, and it is likely that this will never be studied in a randomized trial due to its established efficacy 1.
- Other treatments, such as octreotide and midodrine, have shown promise in treating type I hepatorenal syndrome, but more research is needed to confirm their effectiveness 1.
- The management of cirrhosis patients requiring hemodialysis should focus on supportive care and consideration for liver transplantation, rather than relying solely on hemodialysis as a treatment option.
From the Research
Hemodialysis for Cirrhosis Patients
- Hemodialysis (HD) is a common treatment for end-stage renal disease (ESRD) in cirrhotic patients 2.
- A study found that among cirrhotic patients with ESRD, 98.3% were initiated on HD, while 1.7% were initiated on peritoneal dialysis (PD) 2.
- The same study found that there was no significant difference in in-hospital mortality between cirrhotic patients with ESRD treated with HD and those treated with PD 2.
- However, in a subgroup analysis of cirrhotic patients with ESRD and ascites, PD was found to have a significantly lower in-hospital mortality compared to HD (0% vs 26.67%, p = 0.03) 2.
Variceal Bleeding in Cirrhosis Patients
- Variceal bleeding is a common complication of liver cirrhosis, with a high incidence and mortality rate 3, 4.
- The management of variceal bleeding is complex and often requires a multidisciplinary approach involving pharmacological, endoscopic, and radiologic interventions 3.
- Non-selective beta-blockers (NSBBs) and endoscopic band ligation (EBL) have been shown to be effective in preventing first variceal bleeding 4.
- Vasoactive drugs, such as terlipressin, somatostatin, and octreotide, are also used to treat variceal bleeding, with terlipressin being the preferred agent due to its safety profile and proven efficacy in improving survival 5.
Interplay between Liver, Kidney, and Heart in Cirrhosis Patients
- NSBBs are the cornerstone of primary and secondary prophylaxis of variceal bleeding in cirrhotic patients, but their use can be complex in patients with ascites 6.
- The use of NSBBs in patients with ascites requires careful monitoring, as they can critically impair cardiac reserve and facilitate hemodynamic breakdown, imperiling renal perfusion 6.
- The interplay between the liver, kidney, and heart in cirrhotic patients is complex, and the use of NSBBs and other treatments for portal hypertension must be carefully considered in this context 6.