From the Guidelines
Cirrhosis significantly impacts kidney function, primarily through hepatorenal syndrome (HRS), which is characterized by progressive renal failure without structural kidney damage, and the most recent evidence suggests that the management of HRS typically involves albumin infusion and vasoconstrictors like terlipressin 1.
Pathophysiology of Cirrhosis and Kidney Function
The pathophysiology of cirrhosis and its impact on kidney function is complex, involving multiple mechanisms, including portal hypertension, splanchnic vasodilation, and systemic inflammation, which contribute to decreased effective blood volume, activating compensatory mechanisms that cause renal vasoconstriction and reduced kidney perfusion 1.
Key Factors Impairing Kidney Function
Some key factors that impair kidney function in cirrhosis include:
- Baseline value of serum creatinine (SCr)
- Degree of inflammation
- Degree of cholestasis These factors can influence the response to treatment, such as vasoconstrictors, and highlight the importance of individualized care 1.
Management of Hepatorenal Syndrome
The management of HRS typically involves:
- Albumin infusion
- Vasoconstrictors like terlipressin or norepinephrine
- Addressing the underlying liver disease In severe cases, liver transplantation may be necessary to reverse kidney complications 1.
Recent Evidence and Recommendations
Recent evidence, including the 2024 AGA clinical practice update, emphasizes the importance of vasoactive drugs and intravenous albumin in the management of cirrhosis, particularly in the context of HRS 1.
Clinical Implications
The clinical implications of cirrhosis on kidney function are significant, with a high risk of acute kidney injury and HRS, emphasizing the need for close monitoring and prompt treatment to prevent or reverse kidney damage 1.
From the FDA Drug Label
Patients with cirrhosis, ascites, and a diagnosis of HRS-1 with a rapidly progressive worsening in renal function to a serum creatinine (SCr) ≥2. 25 mg/dL and meeting a trajectory for SCr to double over two weeks, and without sustained improvement in renal function (<20% decrease in SCr and SCr ≥2. 25 mg/dL) 48 hours after both diuretic withdrawal and the beginning of plasma volume expansion with albumin were eligible to participate. The mean serum creatinine was 3. 5 mg/dL
Cirrhosis can impact kidney function by leading to a rapidly progressive worsening in renal function, as evidenced by an increase in serum creatinine levels. In patients with cirrhosis, the kidney function can deteriorate to the point of requiring treatment for Hepatorenal Syndrome (HRS-1), a type of kidney dysfunction that occurs in patients with advanced liver disease. The presence of cirrhosis can lead to Hepatorenal Syndrome, which is characterized by:
- A rapid increase in serum creatinine levels
- A lack of sustained improvement in renal function despite treatment with diuretics and plasma volume expansion The exact mechanism of how cirrhosis affects kidney function is not explicitly stated in the provided text, but it is clear that cirrhosis can lead to significant kidney dysfunction and renal impairment 2.
From the Research
Impact of Cirrhosis on Kidney Function
- Cirrhosis can lead to hepatorenal syndrome (HRS), a serious complication characterized by high mortality without treatment 3.
- HRS is associated with marked impairment of kidney function in response to circulatory and hemodynamic alterations that occur in advanced stages of liver cirrhosis 4.
- The classical definitions of the types of HRS have been recently revisited and 2 forms of HRS have been redefined: the acute form, referred to as acute kidney injury (HRS-AKI), and the chronic form, referred to as chronic kidney disease 4.
Treatment and Management
- Treatment of HRS-AKI is based on the administration of vasoconstrictor drugs in combination with volume expansion with albumin 4.
- The combination of octreotide, midodrine, and albumin has shown possible benefit in improving renal function and short-term survival in patients with HRS type 1 and type 2 5.
- Terlipressin plus albumin is significantly more effective than midodrine and octreotide plus albumin in improving renal function in patients with HRS 3.
- Transjugular intrahepatic portosystemic stent shunt (TIPS) is an effective treatment for type 1 HRS in suitable patients with cirrhosis and ascites, following the improvement of renal function with combination therapy of midodrine, octreotide, and albumin 6.
Prognosis and Quality of Life
- Prognosis of HRS-AKI is poor, and the ideal definitive treatment consists of liver transplantation or simultaneous liver-kidney transplantation 4.
- HRS-AKI has a significant impact on patients' quality of life 4.
- Management of HRS-AKI remains challenging in specific situations such as alcohol-associated hepatitis or metabolic-associated steatotic liver disease cirrhosis 4.