Renal failure in patients with cirrhosis: hepatorenal syndrome and renal support strategies

Abstract

The development of hepatorenal syndrome in liver cirrhosis leads to an increased morbidity and mortality in patients with cirrhosis. Currently, there are no proven methods for the treatment or prevention of hepatorenal syndrome except to maintain adequate hemodynamics and intravascular volume in this patient population. These patients will frequently require renal replacement therapy when presenting for hepatic transplantation. New consensus definitions have been published in order to create uniform standards for classifying and diagnosing acute kidney injury. Two such groups are the Acute Dialysis Quality Initiative (ADQI) and the Acute Kidney Injury Network (AKIN), which have proposed approaches to defining criteria for acute kidney injury. Recent literature supports not only the role of splanchnic vasodilation and systemic vasoconstriction but also heart failure in the pathogenesis of hepatorenal syndrome. The practice of using vasoconstrictor and intravenous albumin therapy for the treatment of hepatorenal syndrome is ongoing with a growing body of recent data supporting the use of vasopressin analogs as the first-line therapy in the ICU setting with knowledge of the possible cardiovascular side-effects. Hepatorenal syndrome, HRS, is a diagnosis of exclusion. There are two forms of hepatorenal syndrome: type 1 hepatorenal syndrome and type 2 hepatorenal syndrome. Type 1 HRS is rapidly progressive and portends a very poor prognosis and has a high mortality rate. Type 2 is more indolent while still associated with an overall poor prognosis. Treatment of HRS is largely still supportive. It is imperative to maintain euvolemia and hemodynamics in this patient population to optimize renal perfusion and preserve renal function. Renal replacement therapy may be necessary in this chronically ill patient population, if renal function deteriorates such that the kidneys cannot maintain metabolic and volume homeostasis. Further research is still necessary as to the prevention and effective treatment for hepatorenal syndrome.