Management of kidney failure in patients with advanced chronic liver disease

Abstract

The management of renal failure in patients with advanced chronic liver disease (ACLD) is crucial due to its high prevalence and associated morbidity and mortality. Renal dysfunction is classified as acute kidney injury (AKI), acute kidney disease (AKD), or chronic kidney disease (CKD), depending on duration and severity, primarily determined by serum creatinine levels, which are essential for AKI subclassification.

The main causes of AKI in ACLD fall into three categories: prerenal, intrinsic, and postrenal. Prerenal causes are the most common, with hepatorenal syndrome (HRS) as the predominant entity.

Portal hypertension is the central mechanism in the pathophysiology of renal impairment in cirrhotic patients. It induces systemic circulatory dysfunction characterized by splanchnic vasodilation, reduced effective arterial blood volume, compensatory renal vasoconstriction, cardiac dysfunction, and a proinflammatory state. These altertions can be exacerbated by precipitating factors such as volume depletion, circulatory failure, nephrotoxic exposure, and inflammatory triggers.

Early diagnostic assessment should include evaluation of intravascular volume status, renal function, and identification of precipitating factors, together with AKI phenotyping. Prompt recognition enables implementation of targeted therapeutic strategies, particularly in hepatorenal syndrome-acute kidney injury (HRS-AKI), where vasoconstrictor therapy has demonstrated significant prognostic benefit.

Keywords: advanced chronic liver disease, kidney failure