Renal Impairment in Cirrhosis Unrelated to Hepatorenal Syndrome

Abstract

P atients with cirrhosis are susceptible to renal impairment as a result of pre-existing circulatory and neurohormonal imbalances, and exposure to precipitating factors. Hampel et al (1) found that acute renal impairment occurred in 24.7% (23 of 96) of hospitalized patients with cirrhosis. In an intensive care unit setting, the incidence of acute renal impairment in cirrhotic patients was reported to be 15.1% (144 of 932) by Peron et al (2) and 39.2% (73 of 186) by du Cheyron et al (3). Terra et al (4) found that 27% (29 of 106) of cirrhotic patients with sepsis unrelated to spontaneous bacterial peritonitis (SBP) developed renal impairment compared with only 8% (eight of 100) of those without infection. Combining the findings of the four aforementioned studies, Garcia-Tsao et al (5) calculated that acute renal impairment occurred in approximately 19% of patients with cirrhosis. In contrast, chronic renal failure is present in 1% of individuals with cirrhosis (5). A variety of etiologies are implicated in the development of renal impairment (Figure 1). These have an impact on clinical presentation, treatment options and prognosis. In a prospective study investigating 562 consecutive patients with cirrhosis and renal impairment (6), three-month survival was 73% for intrinsic renal impairment, 46% for hypovolemia-induced prerenal impairment, 31% for infection-related renal impairment and 15% for hepatorenal syndrome (HRS). The onset of renal impairment in cirrhosis is an important prognostic indicator (7-12). A systematic review of 118 studies by D'Armico et al (10) found that measures of renal impairment (serum creatinine, blood urea nitrogen/azotemia) were strong predictors of mortality in decompensated cirrhosis. In a systematic review of 74 studies, Fede et al (11) found that cirrhotic patients with renal impairment had a >7-fold increased risk for death within one year compared with cirrhotic patients without renal impairment. The one-month and 12-month mortality for patients with renal impairment other than HRS were 56% and 36%, respectively. Renal impairment correlated with death on univariate analysis in 29 studies and on multivariate analysis in 13 studies (11). When serum creatinine was evaluated, it correlated with death on univariate analysis in 16 studies and on multivariate analysis in two studies (11). Serum creatinine level is a variable in calculating the Model for End-stage Liver Disease score -a recognized predictor of the three-month mortality risk and a method used for allocating liver transplants (13,14).Traditionally, renal failure is defined by a serum creatinine threshold of ≥1.5 mg/dL (≥133 μmol/L). However, serum creatinine is not a reliable marker of renal function in cirrhosis because a normal serum creatinine level does not exclude mild disease. Cirrhotic patients may show a lower baseline serum creatinine level than normal due to: reduced endogenous creatinine synthesis from liver dysfunction; decreased conversion of creatine to creatinine as a consequence of Renal impairment is com...

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