Treatment to Improve Acute Kidney Injury in Cirrhosis

Abstract

Acute kidney injury (AKI) is an ominous complication of decompensated cirrhosis, which can be fatal if not treated promptly. It is important that clinicians recognize that AKI has occurred and institute timely treatment. Recent establishment of diagnostic criteria and treatment guidelines are most useful, and these will be further refined as treatments are being modified to improve patient outcome. To manage such a patient, firstly, the cause of the AKI needs to be identified and any precipitating factors corrected. Bacterial infections are a common cause of AKI in cirrhosis, and it is recommended to offer empirical antibiotics in cases of suspicious bacterial infection until all the cultures are negative. Patients should be given albumin infusion in doses of 1 g/kg of body weight for at least 2 days. This can improve the filling of the central circulation, and also absorb many of the bacterial products or inflammatory cytokines that play a role in mediating the renal dysfunction. Often, albumin infusion alone may be sufficient to reverse the AKI. For patients who have acute or type 1 hepatorenal syndrome (HRS1), which is a special form of AKI, pharmacotherapy in the form of vasoconstrictor will be needed. The vasoconstrictor can be terlipressin, norepinephrine, or midodrine, depending on the local availability of drugs or facilities. Currently, approximately 40 % of patients will respond to a combination of vasoconstrictor and albumin. All patients with HRS1 should be assessed for liver transplant. If accepted for liver transplantation, those patients who do not respond to vasocontrictors and albumin need to be started on renal replacement therapy, which otherwise has no place in the treatment of HRS1. Once listed, liver transplantation should occur promptly, preferable under 2 weeks. Otherwise, the chances for renal recovery after liver transplant are significantly reduced, necessitating a renal transplant at the future date.

Evaluation of Absolute Serum Creatinine Changes in Staging of Cirrhosis-Induced Acute Renal Injury and its Association with Long-term Outcomes

“…More recently, the KDIGO criteria have been developed to reach a consensus drawing consolidating elements of both RIFLE and AKIN on staging AKI [15]. Whether these criteria improve the traditional criterion (a final threshold value for sCr of 1.5mg/dl) in terms of a better prediction of mortality is still a matter of debate [16]. Piano et al reported that the traditional criterion was more accurate than the AKIN criteria in the prediction of in-hospital mortality in patients with cirrhosis and ascites [17].…”

The Role of Midodrine for Hypotension Outside of the Intensive Care Unit

“…22 Midodrine has resulted in similar positive outcomes in other cohorts with hepatorenal syndrome. [25][26][27]…”