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Acute kidney injury: prediction, prognostication and optimisation for liver transplant

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Abstract

The definition and diagnostic criteria of renal dysfunction in cirrhosis have undergone significant recent changes. Acute kidney injury (AKI) is defined by a change in serum creatinine of ≥ 26.4 µmol/L (0.3 mg/dL) in < 48 h. Its severity is defined by stages. Chronic kidney disease (CKD) is defined by a reduction in the estimated glomerular filtration rate (GFR) to < 60 mL/min for more than 3 months. Both AKI and CKD can be related to reduced renal perfusion, the so-called functional renal failure; or due to structural damage to the renal parenchyma. Hemodynamic changes and excess inflammation are the pathophysiological processes that predispose the cirrhotic patient to the development of functional AKI. Events that cause further perturbation of hemodynamics or promote further inflammation such as bacterial infection will precipitate AKI. Management starts by removing potential precipitating factors and replenish the intravascular volume. Albumin is the preferred volume expander as it has multiple properties that can significantly reduce the extent of inflammation as well as improving the intravascular volume. Non-responders to albumin infusion should receive vasoconstrictor therapy such as terlipressin, titrated to patient’s blood pressure response, and is effective in approximately 50% of patients. All patients with renal and liver dysfunction should be evaluated for liver transplantation, with renal replacement therapy as a bridge. Guidelines are in place for combined liver and kidney transplants. Future studies on AKI should evaluate the effects of vasoconstrictors on renal function as defined by recent criteria, and to develop biomarkers to identify susceptible patients so to institute treatment early.

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Abbreviations

ACLF:

Acute-on-chronic liver failure

AKI:

Acute kidney injury

ATN:

Acute tubular necrosis

CI:

Confidence interval

CKD:

Chronic kidney disease

DAMP:

Damage associated molecular pattern

EABV:

Effective arterial blood volume

HRS:

Hepatorenal syndrome

ICA:

International Club of Ascites

IL-6:

Interleukin-6

MELD-Na:

Model for end-stage liver disease—sodium

NGAL:

Neutrophil gelatinase-associated lipoprotein

NSBB:

Non-selective beta blocker

OR:

Odds ratio

PAMP:

Pathogen associated molecular pattern

RRT:

Renal replacement therapy

sCr:

Serum creatinine

SBP:

Spontaneous bacterial peritonitis

SIRS:

Systemic inflammatory response syndrome

SLKT:

Simultaneous liver kidney transplant

TNF-α:

Tumour necrosis factor-alpha

UTI:

Urinary tract infection

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  1. Division of Gastroenterology, Department of Medicine, 9th floor, Room 222, Eaton Wing, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G2C4, Canada

    Nishita Jagarlamudi & Florence Wong

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  1. Nishita Jagarlamudi
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Dr. Wong has received consulting fees from Mallinckrodt Pharmaceuticals and Ferring Pharmaceuticals, and research funding from Mallinckrodt Pharmaceuticals and Ferring Pharmaceuticals. Dr. Jagarlamudi has nothing to declare.

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Jagarlamudi, N., Wong, F. Acute kidney injury: prediction, prognostication and optimisation for liver transplant. Hepatol Int 14, 167–179 (2020). https://doi.org/10.1007/s12072-020-10018-0

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