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Malakar S, Rungta S, Samanta A, Shamsul Hoda U, Mishra P, Pande G, Roy A, Giri S, Rai P, Mohindra S, Ghoshal UC. Understanding acute kidney injury in cirrhosis: Current perspective. World J Hepatol 2025; 17:104724. [DOI: 10.4254/wjh.v17.i5.104724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2024] [Revised: 03/13/2025] [Accepted: 04/15/2025] [Indexed: 05/27/2025] Open
Abstract
Acute kidney injury (AKI) is present in 30%-40% of hospitalized patients with cirrhosis. Its incidence is higher in patients with severe alcoholic hepatitis, spontaneous bacterial peritonitis, and acute-on-chronic-liver failure (ACLF). Kidney injury is an important landmark event in the natural history of cirrhosis as it is associated with higher mortality. Overwhelming systemic vasodilation, cardiac dysfunction, hypoperfusion, endotoxemia, and direct nephrotoxicity predispose patients with cirrhosis to kidney injury. Infection is present in 25% of patients with decompensated cirrhosis and 35%-40% of patients with ACLF. Advanced cirrhosis with portal hypertension leads to a sluggish portal flow, leading to increased gut congestion, altered gut permeability and bacterial translocations. They drive infection and endotoxemia in such patients. Pathogen-associated molecular patterns activate inflammatory cascades, which leads to further deterioration in hemodynamics and reduced glomerular filtration rate. Infections and pro-inflammatory cytokines like interleukin 6 (IL-6), IL-1, and tumor necrosis factor alpha may directly cause kidney parenchymal injury. The combined effect of dysfunctional albumin and systemic and splanchnic vasodilatation leads to low effective blood volume, activating the renin-angiotensin-aldosterone system. This causes renal vasoconstriction, water retention, and ascites, which progresses to hepatorenal physiology and AKI development. Vasoconstriction and volume expansion effectively improve arterial blood volume and systemic hemodynamics, thereby improving renal blood flow. It is of paramount importance to predict, detect, and treat AKI in its early state, as progressive renal dysfunction is invariably associated with higher mortality in patients with decompensated cirrhosis and ACLF. This comprehensive review will focus on the recent evolving concepts of the pathophysiology, diagnosis, and management of AKI in patients with cirrhosis.
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Affiliation(s)
- Sayan Malakar
- Department of Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Sumit Rungta
- Department of Medical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Arghya Samanta
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Umair Shamsul Hoda
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Piyush Mishra
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Gaurav Pande
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Akash Roy
- Department of Gastrosciences and Liver Transplantation, Apollo Multispeciality Hospitals, Kolkata 700054, West Bengal, India
| | - Suprabhat Giri
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar 751024, Odisha, India
| | - Praveer Rai
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Samir Mohindra
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
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Sikerwar S, Yao L, Elfarra Y, Jesudian A. Optimal Management of the Inpatient With Decompensated Cirrhosis. J Clin Gastroenterol 2025; 59:420-432. [PMID: 39889207 DOI: 10.1097/mcg.0000000000002143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Accepted: 01/14/2025] [Indexed: 02/02/2025]
Abstract
Over the past several years, there has been a wealth of new data pertaining to the management of complications of cirrhosis, resulting in several important updates to best practices and consensus guidelines. Despite these advancements and numerous recent targeted quality initiatives, hospitalizations resulting from complications of cirrhosis remain frequent, costly and associated with poor patient outcomes. An emphasis on evidence-based management of hospitalized patients with decompensated cirrhosis has the potential to decrease readmission rates and length of stay while improving overall patient outcomes. Herein, we provide an updated, evidence-based overview of the optimal inpatient management of the most frequently encountered complications associated with cirrhosis.
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Affiliation(s)
- Sandeep Sikerwar
- NewYork-Presbyterian Hospital/Columbia University Medical Center
| | - Leah Yao
- NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Yasmine Elfarra
- NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Arun Jesudian
- NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
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3
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Junna S, Nasser S, Sharma P. Renal Dysfunction and Liver Transplantation. Clin Liver Dis 2025; 29:273-285. [PMID: 40287271 DOI: 10.1016/j.cld.2024.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2025]
Abstract
Renal dysfunction is common in patients undergoing liver transplant (LT) evaluation, thereby making it imperative for hepatologists to know how to diagnose, manage, and optimize treatment of acute kidney injury (AKI) and chronic kidney disease. This article reviews pre-transplant, peri-transplant, and post-transplant AKI diagnosis and management, and the role of renal replacement therapy in LT candidates.
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Affiliation(s)
- Shilpa Junna
- Mikati Center for Liver Diseases, Cleveland Clinic Foundation, Cleveland, OH, USA. https://twitter.com/gishilpz
| | - Sarah Nasser
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Pratima Sharma
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA; Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA.
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Alotaibi ME, Kant S. Dual organ transplantation: Pancreas and Liver in the kidney axis. Curr Opin Nephrol Hypertens 2025; 34:164-169. [PMID: 39639839 DOI: 10.1097/mnh.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2024]
Abstract
PURPOSE OF REVIEW This article explores the benefits and challenges of dual organ transplants. RECENT FINDINGS Simultaneous liver-kidney transplant has become a valuable option for patients with both liver and kidney failure, especially since the introduction of clearer eligibility guidelines in 2017. When done for the appropriate candidate, it can significantly improve survival and quality of life. Similarly, simultaneous pancreas-kidney transplantation provides significant advantages for patients with diabetes-related kidney failure by addressing both glycemic control and kidney function, with significant improvement in diabetes associated complications and survival. SUMMARY While these procedures are complex, they offer promising solutions for managing difficult multiorgan conditions. Ongoing research and personalized patient care will be key to maximizing their benefits.
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Affiliation(s)
- Manal E Alotaibi
- Department of Medicine, Medical College, Umm Al-Qura University (UQU), Makkah, Saudi Arabia
| | - Sam Kant
- Department of Renal Medicine, St. Vincent's University Hospital, University College Dublin, Dublin, Ireland
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Banegas-Deras EJ, Mazón-Ruiz J, Romero-González G, Ruiz-Cobo JC, Sanz-García C, Serrano-Soto M, Sánchez E, Argaiz ER. Acute kidney injury and point-of-care ultrasound in liver cirrhosis: redefining hepatorenal syndrome. Clin Kidney J 2024; 17:sfae112. [PMID: 38726210 PMCID: PMC11079671 DOI: 10.1093/ckj/sfae112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Indexed: 05/12/2024] Open
Abstract
Acute kidney injury (AKI) in patients with cirrhosis is a diagnostic challenge due to multiple and sometimes overlapping possible etiologies. Many times, diagnosis cannot be made based on case history, physical examination or laboratory data, especially when the nephrologist is faced with AKI with a hemodynamic basis, such as hepatorenal syndrome. In addition, the guidelines still include generalized recommendations regarding withdrawal of diuretics and plasma volume expansion with albumin for 48 h, which may be ineffective and counterproductive and may have iatrogenic effects, such as fluid overload and acute cardiogenic pulmonary edema. For this reason, the use of new tools, such as hemodynamic point-of-care ultrasound (PoCUS), allows us to phenotype volume status more accurately and ultimately guide medical treatment in a noninvasive, rapid and individualized manner.
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Affiliation(s)
| | - Jaime Mazón-Ruiz
- Nephrology Department, Central University Hospital of Asturias, Oviedo, Spain
| | - Gregorio Romero-González
- Nephrology Department, Germans Trias i Pujol University Hospital, Badalona, Spain
- International Renal Research Institute of Vicenza, Vicenza, Italy
| | - Juan Carlos Ruiz-Cobo
- Liver Unit, Vall d'Hebron University Hospital, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Clara Sanz-García
- Nephrology Department, Grande Covián de Arriondas Hospital, Arriondas, Spain
| | - Mara Serrano-Soto
- International Renal Research Institute of Vicenza, Vicenza, Italy
- Nephrology Department, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Emilio Sánchez
- Nephrology Department, Cabueñes University Hospital, Gijón, Spain
| | - Eduardo R Argaiz
- Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City, Mexico
- Departamento de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Agarwal A, Beddhu S, Boucher R, Rao V, Ramkumar N, Rodan AR, Fang J, Wynne BM, Drakos SG, Hanff T, Cheung AK, Fang JC. Evaluation of renal sodium handling in heart failure with preserved ejection fraction: A pilot study. Physiol Rep 2024; 12:e16033. [PMID: 38740564 PMCID: PMC11090885 DOI: 10.14814/phy2.16033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/19/2024] [Accepted: 04/14/2024] [Indexed: 05/16/2024] Open
Abstract
The pathophysiology behind sodium retention in heart failure with preserved ejection fraction (HFpEF) remains poorly understood. We hypothesized that patients with HFpEF have impaired natriuresis and diuresis in response to volume expansion and diuretic challenge, which is associated with renal hypo-responsiveness to endogenous natriuretic peptides. Nine HFpEF patients and five controls received saline infusion (0.25 mL/kg/min for 60 min) followed by intravenous furosemide (20 mg or home dose) 2 h after the infusion. Blood and urine samples were collected at baseline, 2 h after saline infusion, and 2 h after furosemide administration; urinary volumes were recorded. The urinary cyclic guanosine monophosphate (ucGMP)/plasma B-type NP (BNP) ratio was calculated as a measure of renal response to endogenous BNP. Wilcoxon rank-sum test was used to compare the groups. Compared to controls, HFpEF patients had reduced urine output (2480 vs.3541 mL; p = 0.028), lower urinary sodium excretion over 2 h after saline infusion (the percentage of infused sodium excreted 12% vs. 47%; p = 0.003), and a lower baseline ucGMP/plasma BNP ratio (0.7 vs. 7.3 (pmol/mL)/(mg/dL)/(pg/mL); p = 0.014). Patients with HFpEF had impaired natriuretic response to intravenous saline and furosemide administration and lower baseline ucGMP/plasma BNP ratios indicating renal hypo-responsiveness to NPs.
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Affiliation(s)
- Adhish Agarwal
- Division of Nephrology and Hypertension, Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
- Medical Service, Veterans Affairs Salt Lake City Health Care SystemSalt Lake CityUtahUSA
| | - Srinivasan Beddhu
- Division of Nephrology and Hypertension, Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
- Medical Service, Veterans Affairs Salt Lake City Health Care SystemSalt Lake CityUtahUSA
| | - Robert Boucher
- Division of Nephrology and Hypertension, Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Veena Rao
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Nirupama Ramkumar
- Division of Nephrology and Hypertension, Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Aylin R. Rodan
- Division of Nephrology and Hypertension, Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
- Medical Service, Veterans Affairs Salt Lake City Health Care SystemSalt Lake CityUtahUSA
- Department of Human GeneticsUniversity of UtahSalt Lake CityUtahUSA
| | - Jacob Fang
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Brandi M. Wynne
- Division of Nephrology and Hypertension, Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Stavros G. Drakos
- Medical Service, Veterans Affairs Salt Lake City Health Care SystemSalt Lake CityUtahUSA
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Thomas Hanff
- Medical Service, Veterans Affairs Salt Lake City Health Care SystemSalt Lake CityUtahUSA
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Alfred K. Cheung
- Division of Nephrology and Hypertension, Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - James C. Fang
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
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7
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Belcher JM. Hepatorenal Syndrome Type 1: Diagnosis and Treatment. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:100-110. [PMID: 38649214 DOI: 10.1053/j.akdh.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 04/16/2023] [Accepted: 05/08/2023] [Indexed: 04/25/2024]
Abstract
Hepatorenal syndrome (HRS) is a feared complication in patients with advanced cirrhosis and is associated with significant morbidity and mortality. While recognized as a distinct physiologic condition for well over one hundred years, a lack of objective diagnostic tests has made the diagnosis one of exclusion. Since 1979, multiple sets of diagnostic criteria have been proposed. Though varying in detail, the principal intent of these criteria is to identify patients with severe, functional acute kidney injury that is unresponsive to volume resuscitation and exclude those with structural injury. However, accurate differential diagnosis remains challenging. Recently, multiple urinary biomarkers of kidney injury, including neutrophil gelatinase-associated lipocalin, have been studied as a means of objectively phenotyping etiologies of acute kidney injury in patients with cirrhosis. Along with markers reflecting tubular functional integrity, including the fractional excretion of sodium, injury markers will likely be incorporated into future diagnostic criteria. Making an accurate diagnosis is critical, as therapeutic options exist for HRS but must be given in a timely manner and only to those patients likely to benefit. Terlipressin, an analog of vasopressin, is the first line of therapy for HRS in much of the world and has recently been approved for use in the United States. Significant questions remain regarding the optimal dosing strategy, metrics for titration, and the potential role of point-of-care ultrasound to help guide concurrent albumin administration.
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Affiliation(s)
- Justin M Belcher
- Yale University School of Medicine, Department of Internal Medicine, Section of Nephrology, New Haven, CT; Department of Internal Medicine, Section of Nephrology, VA Connecticut Healthcare, West Haven, CT.
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8
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Giammarino A, Kalia H. A hospitalist's approach to managing acute kidney injury (hepatorenal syndrome) in cirrhosis. Clin Liver Dis (Hoboken) 2024; 23:e0159. [PMID: 38681513 PMCID: PMC11049700 DOI: 10.1097/cld.0000000000000159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/17/2024] [Indexed: 05/01/2024] Open
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Badura K, Frąk W, Hajdys J, Majchrowicz G, Młynarska E, Rysz J, Franczyk B. Hepatorenal Syndrome-Novel Insights into Diagnostics and Treatment. Int J Mol Sci 2023; 24:17469. [PMID: 38139297 PMCID: PMC10744165 DOI: 10.3390/ijms242417469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
Hepatorenal syndrome (HRS) is a disorder associated with cirrhosis and renal impairment, with portal hypertension as its major underlying cause. Moreover, HRS is the third most common cause of acute kidney injury, thus creating a major public health concern. This review summarizes the available information on the pathophysiological implications of HRS. We discuss pathogenesis associated with HRS. Mechanisms such as dysfunction of the circulatory system, bacterial infection, inflammation, impaired renal autoregulation, circulatory, and others, which have been identified as critical pathways for development of HRS, have become easier to diagnose in recent years. Additionally, relatively recently, renal dysfunction biomarkers have been found indicating renal injury, which are involved in the pathophysiology of HRS. This review also summarizes the available information on the management of HRS, focusing on vasoconstrictive drugs, renal replacement therapy, and liver transplant together with currently being investigated novel therapies. Analyzing new discoveries for the underlying causes of this condition assists the general research to improve understanding of the mechanism of pathophysiology and thus prevention of HRS.
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Affiliation(s)
- Krzysztof Badura
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Weronika Frąk
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Joanna Hajdys
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Gabriela Majchrowicz
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
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Choi JC, Yoo JJ. [Hepatorenal Syndrome]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2023; 82:224-232. [PMID: 37997218 DOI: 10.4166/kjg.2023.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/16/2023] [Accepted: 09/19/2023] [Indexed: 11/25/2023]
Abstract
Hepatorenal syndrome (HRS) is a critical and potentially life-threatening complication of advanced liver disease, including cirrhosis. It is characterized by the development of renal dysfunction in the absence of underlying structural kidney pathology. The pathophysiology of HRS involves complex interactions between systemic and renal hemodynamics, neurohormonal imbalances, and the intricate role of vasoconstrictor substances. Understanding these mechanisms is crucial for the timely identification and management of HRS. The diagnosis of HRS is primarily clinical and relies on specific criteria that consider the exclusion of other causes of renal dysfunction. The management of HRS comprises two main approaches: vasoconstrictor therapy and albumin infusion, which aim to improve renal perfusion and mitigate the hyperdynamic circulation often seen in advanced liver disease. Additionally, strategies such as liver transplantation and renal replacement therapy are essential considerations based on individual patient characteristics and disease severity. This review article provides a comprehensive overview of hepatorenal syndrome, focusing on its pathophysiology, diagnostic criteria, and current management strategies.
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Affiliation(s)
- Jun Cheol Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jeong-Ju Yoo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
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11
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Jung CY, Chang JW. Hepatorenal syndrome: Current concepts and future perspectives. Clin Mol Hepatol 2023; 29:891-908. [PMID: 37050843 PMCID: PMC10577351 DOI: 10.3350/cmh.2023.0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/10/2023] [Accepted: 04/10/2023] [Indexed: 04/14/2023] Open
Abstract
Hepatorenal syndrome (HRS), a progressive but potentially reversible deterioration of kidney function, remains a major complication in patients with advanced cirrhosis, often leading to death before liver transplantation (LT). Recent updates in the pathophysiology, definition, and classification of HRS have led to a complete revision of the nomenclature and diagnostic criteria for HRS type 1, which was renamed HRS-acute kidney injury (AKI). HRS is characterized by severe impairment of kidney function due to increased splanchnic blood flow, activation of several vasoconstriction factors, severe vasoconstriction of the renal arteries in the absence of kidney histologic abnormalities, nitric oxide dysfunction, and systemic inflammation. Diagnosis of HRS remains a challenge because of the lack of specific diagnostic biomarkers that accurately distinguishes structural from functional AKI, and mainly involves the differential diagnosis from other forms of AKI, particularly acute tubular necrosis. The optimal treatment of HRS is LT. While awaiting LT, treatment options include vasoconstrictor drugs to counteract splanchnic arterial vasodilation and plasma volume expansion by intravenous albumin infusion. In patients with HRS unresponsive to pharmacological treatment and with conventional indications for kidney replacement therapy (KRT), such as volume overload, uremia, or electrolyte imbalances, KRT may be applied as a bridging therapy to transplantation. Other interventions, such as transjugular intrahepatic portosystemic shunt, and artificial liver support systems have a very limited role in improving outcomes in HRS. Although recently developed novel therapies have potential to improve outcomes of patients with HRS, further studies are warranted to validate the efficacy of these novel agents.
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Affiliation(s)
- Chan-Young Jung
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jai Won Chang
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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12
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Mazumder NR, Junna S, Sharma P. The Diagnosis and Non-pharmacological Management of Acute Kidney Injury in Patients with Cirrhosis. Clin Gastroenterol Hepatol 2023; 21:S11-S19. [PMID: 37625862 DOI: 10.1016/j.cgh.2023.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/01/2023] [Accepted: 04/06/2023] [Indexed: 08/27/2023]
Abstract
Acute kidney injury in patients with cirrhosis is quite common, and is seen in up to 50% of patients hospitalized for decompensated cirrhosis. Causes of acute kidney injury include prerenal, renal, or postrenal etiologies. The diagnosis and early institution of nonpharmacologic and pharmacologic management are key to the recovery of renal function. The objective of this review is to provide a practical approach to the use of diagnostic biomarkers and highlight the nonpharmacologic management and prevention of acute kidney injury.
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Affiliation(s)
- Nikhilesh R Mazumder
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan; Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Shilpa Junna
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan; Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.
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Arnold J, Avila E, Idalsoaga F, Diaz LA, Ayala Valverde M, Ayares G, Arrese M, Roessler E, Huidobro JP, Hudson D, Khan MQ, Arab JP. Advances in the diagnosis and management of hepatorenal syndrome: insights into HRS-AKI and liver transplantation. EGASTROENTEROLOGY 2023; 1:e100009. [PMID: 39943997 PMCID: PMC11770447 DOI: 10.1136/egastro-2023-100009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/27/2023] [Indexed: 01/04/2025]
Abstract
In hepatorenal syndrome-acute kidney injury (HRS-AKI), accurate and early diagnosis is crucial. HRS is a severe condition seen in advanced cirrhosis, requiring prompt recognition and proper management to enhance patient outcomes. Diagnosis of HRS-AKI relies on serum creatinine elevations, similar to other AKI cases in cirrhosis. However, distinguishing HRS-AKI from other renal impairments in these patients can be challenging. Biomarkers and clinical criteria aid in diagnosis and guide treatment. The management of HRS-AKI initially involves improving the haemodynamic profile using albumin and vasoconstrictors like terlipressin, a synthetic vasopressin analogue. Despite some reports linking terlipressin to increased adverse events compared with norepinephrine, it remains the preferred choice in HRS-AKI and acute-on-chronic liver failure due to its faster, stronger response and improved survival. Additional therapies like midodrine (alpha-1 adrenergic agonist), octreotide (somatostatin analogue) and transjugular intrahepatic portosystemic shunt are proposed as adjuvant treatments for HRS-AKI, aiming to improve vasoconstriction and renal blood flow. However, these adjunctive therapies cannot replace the definitive treatment for HRS-AKI-liver transplantation (LT). In cases unresponsive to medical management, LT is the only option to restore liver function and improve renal outcomes. Current evidence favours combined liver and kidney transplantation (CLKT) in certain situations. This review aims to evaluate the present evidence and recommendations on AKI in patients with cirrhosis, the pathophysiology of HRS-AKI, different treatments and indications for LT and CLKT. Understanding the complexities of managing HRS-AKI is crucial for optimising patient care and achieving better outcomes in this challenging clinical setting.
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Affiliation(s)
- Jorge Arnold
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo Avila
- Departamento de Nefrología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Idalsoaga
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis Antonio Diaz
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Gustavo Ayares
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marco Arrese
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eric Roessler
- Departamento de Nefrología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan Pablo Huidobro
- Departamento de Nefrología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - David Hudson
- Department of Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Mohammad Qasim Khan
- Department of Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Juan Pablo Arab
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Medicine, London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Ibáñez-Samaniego L, Baines A, Bañares R. Afectación renal en la enfermedad hepática crónica avanzada. Síndrome hepatorrenal. MEDICINE - PROGRAMA DE FORMACIÓN MÉDICA CONTINUADA ACREDITADO 2023; 13:4841-4849. [DOI: 10.1016/j.med.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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15
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Affiliation(s)
- Mitra K Nadim
- From the Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles (M.K.N.); and the Section of Digestive Diseases, Yale University School of Medicine, New Haven, and the Section of Digestive Diseases, Veterans Affairs Connecticut Healthcare System, West Haven - both in Connecticut (G.G.-T.)
| | - Guadalupe Garcia-Tsao
- From the Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles (M.K.N.); and the Section of Digestive Diseases, Yale University School of Medicine, New Haven, and the Section of Digestive Diseases, Veterans Affairs Connecticut Healthcare System, West Haven - both in Connecticut (G.G.-T.)
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16
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Flamm SL, Wong F, Ahn J, Kamath PS. AGA Clinical Practice Update on the Evaluation and Management of Acute Kidney Injury in Patients With Cirrhosis: Expert Review. Clin Gastroenterol Hepatol 2022; 20:2707-2716. [PMID: 36075500 DOI: 10.1016/j.cgh.2022.08.033] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/15/2022] [Accepted: 08/18/2022] [Indexed: 02/07/2023]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available published evidence and expert advice regarding the clinical management of patients with suspected acute kidney injury in patients with cirrhosis. METHODS This article provides practical advice for the management of patients with cirrhosis and acute kidney injury based on the best available published evidence. This best practice document is not based on a formal systematic review. This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through the standard procedures of Clinical Gastroenterology & Hepatology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Since systematic reviews were not performed, these BPA statements do not carry formal ratings of the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: Acute kidney injury (AKI) should be diagnosed when the serum creatinine increases by ≥0.3 mg/dL within 48 hours or is ≥50% from baseline or when the urine output is reduced below 0.5 mL/kg/h for >6 hours. BEST PRACTICE ADVICE 2: Preventive measures against the development of AKI in cirrhosis include (1) avoidance of potentially nephrotoxic medications like nonsteroidal anti-inflammatory drugs (NSAIDs), (2) avoidance of excessive or unmonitored diuretics or nonselective beta-blockade, (3) avoidance of large-volume paracentesis without albumin replacement, and (4) counseling patients to avoid alcohol use. BEST PRACTICE ADVICE 3: (A) Investigation is directed to determining the cause of AKI, which can be due to hypovolemic causes (volume responsive, and the most common cause of AKI in patients with cirrhosis); acute tubular necrosis; hepatorenal syndrome with AKI (HRS-AKI) (a functional renal failure that persists despite volume repletion); HRS with acute kidney disease, a type of functional renal failure of <3 months- duration in which criteria for HRS-AKI are not met; or postrenal, which occurs only rarely. (B) The specific type of AKI should be identified through a careful history, physical examination, blood biochemistry, urine microscopic examination, urine chemistry (Na+ and urea) and selected urinary biomarkers, and renal ultrasound. BEST PRACTICE ADVICE 4: A rigorous search for infection is required in all patients with AKI. A diagnostic paracentesis should be carried out to evaluate for spontaneous bacterial peritonitis; blood and urine cultures and chest radiograph are also required. There is no role for routine prophylactic antibiotics in patients with AKI, but broad-spectrum antibiotics should be started whenever infection is strongly suspected. BEST PRACTICE ADVICE 5: When AKI is diagnosed, diuretics and nonselective beta-blockers should be held, NSAIDs discontinued, the precipitating cause of AKI treated, and fluid losses replaced, administering albumin 1 g/kg/d for 2 days if the serum creatinine shows doubling from baseline. Urine output, vital signs, and when indicated, echocardiography or CVP (if there is a pre-existing central line) should be used to monitor fluid status. BEST PRACTICE ADVICE 6: When the serum creatinine remains higher than twice the baseline value despite these measures, treatment of HRS-AKI should be initiated with albumin at a dose of 1 g/kg intravenously on day 1 followed by 20-40 g daily along with vasoactive agents (terlipressin; if terlipressin is not available, either a combination of octreotide and midodrine; or norepinephrine, depending on institutional preferences) and continued either until 24 hours following the return of the serum creatinine level to within ≤0.3 mg/dL of baseline for 2 consecutive days or for a total of 14 days of therapy. BEST PRACTICE ADVICE 7: Terlipressin should be initiated as a bolus dose of 1 mg every 4-6 hours (total 4-6 mg/d). The dose should be increased to a maximum of 2 mg every 4-6 hours (total 8-12 mg/d) if there is no reduction in serum creatinine at day 3 of therapy by at least 25% compared to the baseline value. Alternatively, clinicians can administer terlipressin by continuous intravenous infusion at a lower starting dose of 2 mg/d, which may reduce ischemic side effects and increase the dose gradually every 24-48 hours up to a maximum dose of 12 mg/d, or reversal of HRS. As per Food and Drug Administration restrictions, terlipressin should not be used in patients with a serum creatinine ≥5 mg/dL, or oxygen saturation of <90%. BEST PRACTICE ADVICE 8: Oral midodrine when used should be initiated at doses of 7.5 mg and titrated upward to 12.5 mg 3 times daily with octreotide (starting with 100 μg and titrating upward to 200 μg subcutaneously 3 times daily). BEST PRACTICE ADVICE 9: Norepinephrine should be used as a continuous intravenous infusion at a starting dose of 0.5 mg/h and the dose increased every 4 hours by 0.5 mg/h to a maximum of 3 mg/h with the goal of increasing the mean arterial pressure by ≥10 mm Hg and/or the urine output to >50 mL/h for at least 4 hours. BEST PRACTICE ADVICE 10: The risks of ischemic side effects of terlipressin and norepinephrine include angina and ischemia of fingers, skin, and intestine. These side effects may be lowered by starting at the lowest dose and gradually titrating upward. BEST PRACTICE ADVICE 11: Fluid status should be closely monitored because of the risk of pulmonary edema with excessive use of albumin. BEST PRACTICE ADVICE 12: Renal replacement therapy (RRT) may be used in the management of (A) AKI secondary to acute tubular necrosis; (B) HRS-AKI in potential candidates for liver transplantation (that is, RRT should not be used in patients with HRS-AKI who are not candidates for liver transplantation); and (C) AKI of uncertain etiology in which the need for RRT may be considered on an individual basis. BEST PRACTICE ADVICE 13: Transjugular intrahepatic portosystemic shunts should not be used as a specific treatment of HRS-AKI. BEST PRACTICE ADVICE 14: Liver transplantation is the most effective treatment for HRS-AKI. Pharmacotherapy for HRS-AKI before proceeding with liver transplantation may be associated with better post-liver transplantation outcomes. Selected patients with HRS-AKI may require simultaneous liver kidney transplantation based on updated Organ Procurement and Transplantation Network listing criteria.
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Affiliation(s)
- Steven L Flamm
- Division of Gastroenterology and Hepatology, Rush University Medical College, Chicago, Illinois
| | - Florence Wong
- Division of Gastroenterology and Hepatology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joseph Ahn
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.
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Pelayo J, Lo KB, Sultan S, Quintero E, Peterson E, Salacupa G, Zanoria MA, Guarin G, Helfman B, Sanon J, Mathew R, Yazdanyar A, Navarro V, Pressman G, Rangaswami J. Invasive hemodynamic parameters in patients with hepatorenal syndrome. IJC HEART & VASCULATURE 2022; 42:101094. [PMID: 36032268 PMCID: PMC9399284 DOI: 10.1016/j.ijcha.2022.101094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/28/2022] [Accepted: 07/17/2022] [Indexed: 11/30/2022]
Abstract
Background Hepatorenal syndrome (HRS), a form of kidney dysfunction frequent in cirrhotic patients, is characterized by low filling pressures and impaired kidney perfusion due to peripheral vasodilation and reduced effective circulatory volume. Cardiorenal syndrome (CRS), driven by renal venous hypertension and elevated filling pressures, is a separate cause of kidney dysfunction in cirrhotic patients. The two entities, however, have similar clinical phenotypes. To date, limited invasive hemodynamic data are available to help distinguish the primary forces behind worsened kidney function in cirrhotic patients. Objective Our aim was to analyze invasive hemodynamic profiles and kidney outcomes in patients with cirrhosis who met criteria for HRS. Methods We conducted a single center retrospective study among cirrhotic patients with worsening kidney function admitted for liver transplant evaluation between 2010 and 2020. All met accepted criteria for HRS and underwent concurrent right heart catheterization (RHC). Results 127 subjects were included. 79 had right atrial pressure >10 mmHg, 79 had wedge pressure >15 mmHg, and 68 had both. All patients with elevated wedge pressure were switched from volume loading to diuretics resulting in significant reductions between admission and post diuresis creatinine values (2.0 [IQR 1.5–2.8] vs 1.5 [IQR 1.2–2.2]; p = 0.003). Conclusion 62% of patients diagnosed with HRS by clinical criteria have elevated filling pressures. Improvement of renal function after diuresis suggests the presence of CRS physiology in these patients. Invasive hemodynamic data profiling can lead to meaningful change in management of cirrhotic patients with worsened kidney function, guiding appropriate therapies based on filling pressures.
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Affiliation(s)
- Jerald Pelayo
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, United States
- Corresponding author at: 5501 Old York Road, Philadelphia, PA 19141, United States.
| | - Kevin Bryan Lo
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, United States
| | - Sahar Sultan
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, United States
| | - Eduardo Quintero
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, United States
| | - Eric Peterson
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, United States
| | - Grace Salacupa
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, United States
| | | | - Geneva Guarin
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, United States
| | - Beth Helfman
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, United States
| | - Julien Sanon
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA, United States
- Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Roy Mathew
- Division of Nephrology, VA Health Care System, Loma Linda University, CA, United States
| | - Ali Yazdanyar
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA, United States
- Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Victor Navarro
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, United States
- Division of Liver Disease and Transplantation, Einstein Medical Center, Philadelphia, PA, United States
| | - Gregg Pressman
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, United States
- Division of Cardiology, Einstein Medical Center, Philadelphia, PA, United States
| | - Janani Rangaswami
- Department of Medicine, George Washington University, Washington, DC, United States
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Velez JCQ. Hepatorenal Syndrome Type 1: From Diagnosis Ascertainment to Goal-Oriented Pharmacologic Therapy. KIDNEY360 2022; 3:382-395. [PMID: 35373127 PMCID: PMC8967638 DOI: 10.34067/kid.0006722021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/02/2021] [Indexed: 05/05/2023]
Abstract
Hepatorenal syndrome type 1 (HRS-1) is a serious form of AKI that affects individuals with advanced cirrhosis with ascites. Prompt and accurate diagnosis is essential for effective implementation of therapeutic measures that can favorably alter its clinical course. Despite decades of investigation, HRS-1 continues to be primarily a diagnosis of exclusion. Although the diagnostic criteria dictated by the International Club of Ascites provide a useful framework to approach the diagnosis of HRS-1, they do not fully reflect the complexity of clinical scenarios that is often encountered in patients with cirrhosis and AKI. Thus, diagnostic uncertainty is often faced. In particular, the distinction between HRS-1 and acute tubular injury is challenging with the currently available clinical tools. Because treatment of HRS-1 differs from that of acute tubular injury, distinguishing these two causes of AKI has direct implications in management. Therefore, the use of the International Club of Ascites criteria should be enhanced with a more individualized approach and attention to the other phenotypic aspects of HRS-1 and other types of AKI. Liver transplantation is the most effective treatment for HRS-1, but it is only available to a small fraction of the affected patients worldwide. Thus, pharmacologic therapy is necessary. Vasoconstrictors aimed to increase mean arterial pressure constitute the most effective approach. Administration of intravenous albumin is an established co-adjuvant therapy. However, the risk for fluid overload in patients with cirrhosis with AKI is not negligible, and interventions intended to expand or remove volume should be tailored to the specific needs of the patient. Norepinephrine and terlipressin are the most effective vasoconstrictors, and their use should be determined by availability, ease of administration, and attention to optimal risk-benefit balance for each clinical scenario.
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Affiliation(s)
- Juan Carlos Q. Velez
- Department of Nephrology, Ochsner Health, New Orleans, Louisiana
- Ochsner Clinical School, University of Queensland, Brisbane, Australia
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Gowda YH, Jagtap N, Karyampudi A, Rao NP, Deepika G, Sharma M, Gupta R, Tandan M, Ramchandani M, John P, Kulkarni A, Kumar P, Bhaware B, Turpati MV, Reddy DN. Fractional Excretion of Sodium and Urea in Differentiating Acute Kidney Injury Phenotypes in Decompensated Cirrhosis. J Clin Exp Hepatol 2022; 12:899-907. [PMID: 35677524 PMCID: PMC9168716 DOI: 10.1016/j.jceh.2021.09.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 09/20/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Prerenal acute kidney injury (prerenal AKI), hepatorenal syndrome (HRS-AKI), and acute tubular necrosis (ATN-AKI) are the various phenotypes of acute kidney injury, which are described in decompensated cirrhosis. It has therapeutic and prognostic implications. We aimed to evaluate the diagnostic utility of fractional excretion of sodium and urea (FENa and FEUrea) for differentiating AKI phenotypes. METHODS A prospective analysis was performed in 200 patients with decompensated cirrhosis with AKI to derive receiver operating curve, optimal cut-off, sensitivity, and specificity. These findings were validated in an independent cohort (n = 50) to differentiate ATN-AKI, HRS-AKI, and prerenal AKI. RESULTS The incidence of prerenal AKI, HRS-AKI, and ATN-AKI were 37.5%, 34%, and 28.5% in the derivation cohort and 28%, 38%, and 34% in the validation cohort respectively. The median FENa was significantly different in various phenotypes of AKI in the derivation and validation cohort (P 0.001); FEUrea was significantly different in the derivation cohort (P 0.0001), not in the validation cohort (P 0.106). The AUC for FENa (cut-off, sensitivity/specificity) was 86.6% (0.567, 89/71) and for FEUrea was 60.3% (34.73, 70/58) for ATN-AKI vs. non-ATN-AKI. The area under the curve for FENa to differentiate between HRS-AKI vs. non-HRS-AKI was 74.5%. FEUrea could not differentiate HRS-AKI vs. non-HRS-AKI (AUC 60.4%) satisfactorily. FENa and FEUrea were unable to differentiate between prerenal AKI and HRS-AKI (AUC <70%). CONCLUSION Among cirrhotics FENa at admission is a simple, commonly available clinical tool that can be used to differentiate structural AKI from prerenal AKI and HRS-AKI. The newly derived lowered cut-off value of FENa makes the diagnosis of ATN-AKI easier, faster and thus obviates the need for extensive workup in a significant proportion of patients. FENa appears better than FEUrea in decompensated cirrhosis with AKI.
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Key Words
- AKI, Acute Kidney Injury
- ATN–AKI, Acute Tubular Necrosis – Acute Kidney Injury
- AUC, Area Under Curve
- FENa, Fractional Excretion of Sodium
- FEUrea, Fractional Excretion of Urea
- HRS–AKI, Hepato Renal Syndrome Acute Kidney Injury
- ICA, International Club of Ascites
- IL-18, Interleukin-18
- IQR, Interquartile range
- KIM-1, Kidney Injury Molecule – 1
- L-FABP, Liver Type Fatty Acid-Binding Protein
- NGAL, Neutrophil Gelatinase – Associated lipocalin
- Prerenal AKI, Prerenal Acute Kidney Injury
- ROC, Receiver Operating Curve
- acute kidney injury
- cirrhosis
- fractional excretion of sodium
- fractional excretion of urea
- hepatorenal syndrome
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Affiliation(s)
- Yashavanth H.S. Gowda
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Nitin Jagtap
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India,Address for correspondence: Dr. Nitin Jagtap, MD, DNB, Consultant Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, 500082, India. Tel.: +91 9182859523.
| | - Arun Karyampudi
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Nagaraja P. Rao
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Gujjarapudi Deepika
- Department of Biochemistry, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mithun Sharma
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rajesh Gupta
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Manu Tandan
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan Ramchandani
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Priyadarshini John
- Department of Nephrology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Anand Kulkarni
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Pramod Kumar
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Bhushan Bhaware
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan V. Turpati
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D. Nageshwar Reddy
- Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
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20
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Hepatorenal syndrome: pathophysiology and evidence-based management update. ROMANIAN JOURNAL OF INTERNAL MEDICINE 2021; 59:227-261. [DOI: 10.2478/rjim-2021-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Indexed: 11/20/2022] Open
Abstract
Abstract
Hepatorenal syndrome (HRS) is a functional renal failure that develops in patients with advanced hepatic cirrhosis with ascites and in those with fulminant hepatic failure. The prevalence of HRS varies among studies but in general it is the third most common cause of acute kidney injury (AKI) in cirrhotic patients after pre-renal azotemia and acute tubular necrosis. HRS carries a grim prognosis with a mortality rate approaching 90% three months after disease diagnosis. Fortunately, different strategies have been proven to be successful in preventing HRS. Although treatment options are available, they are not universally effective in restoring renal function but they might prolong survival long enough for liver transplantation, which is the ultimate treatment. Much has been learned in the last two decades regarding the pathophysiology and management of this disease which lead to notable evolution in the HRS definition and better understanding on how best to manage HRS patients. In the current review, we will summarize the recent advancement in epidemiology, pathophysiology, and management of HRS.
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21
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El-Khoury JM, Hoenig MP, Jones GRD, Lamb EJ, Parikh CR, Tolan NV, Wilson FP. AACC Guidance Document on Laboratory Investigation of Acute Kidney Injury. J Appl Lab Med 2021; 6:1316-1337. [PMID: 33973621 DOI: 10.1093/jalm/jfab020] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a sudden episode of kidney damage or failure affecting up to 15% of hospitalized patients and is associated with serious short- and long-term complications, mortality, and health care costs. Current practices to diagnose and stage AKI are variable and do not factor in our improved understanding of the biological and analytical variability of creatinine. In addition, the emergence of biomarkers, for example, cystatin C, insulin-like growth factor binding protein 7, and tissue inhibitor of metalloproteinases 2, and electronic notification tools for earlier detection of AKI, highlights the need for updated recommendations to address these developments. CONTENT This AACC Academy guidance document is intended to provide laboratorians and clinicians up-to-date information regarding current best practices for the laboratory investigation of AKI. Topics covered include: clinical indications for further investigating potential AKI, analytical considerations for creatinine assays, the impact of biological variability on diagnostic thresholds, defining "baseline" creatinine, role of traditional markers (urine sodium, fractional excretion of sodium, fractional excretion of urea, and blood urea-to-creatinine ratio), urinary microscopic examination, new biomarkers, improving AKI-associated test utilization, and the utility of automated AKI alerts. SUMMARY The previous decade brought us a significant number of new studies characterizing the performance of existing and new biomarkers, as well as potential new tools for early detection and notification of AKI. This guidance document is intended to inform clinicians and laboratorians on the best practices for the laboratory investigation of AKI, based on expert recommendations where the preponderance of evidence is available.
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Affiliation(s)
- Joe M El-Khoury
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Melanie P Hoenig
- Renal Division, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Edmund J Lamb
- Department of Pathology, East Kent Hospitals University NHS Foundation Trust, Kent, UK
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins University, Baltimore, MD, USA
| | - Nicole V Tolan
- Department of Pathology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - F Perry Wilson
- Program of Applied Translational Research, Yale School of Medicine, New Haven, CT, USA
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22
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Flamm SL, Brown K, Wadei HM, Brown RS, Kugelmas M, Samaniego‐Picota M, Burra P, Poordad F, Saab S. The Current Management of Hepatorenal Syndrome-Acute Kidney Injury in the United States and the Potential of Terlipressin. Liver Transpl 2021; 27:1191-1202. [PMID: 33848394 PMCID: PMC8457138 DOI: 10.1002/lt.26072] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/24/2021] [Accepted: 03/31/2021] [Indexed: 12/16/2022]
Abstract
Acute kidney injury (AKI) in the setting of cirrhosis (hepatorenal syndrome [HRS]-AKI) is a severe and often fatal complication of end-stage liver disease. The goals of treatment are to reverse renal failure and prolong survival in patients who are critically ill. However, interventions have limited efficacy, and mortality rates remain high. In the United States, the mainstay of pharmacologic therapy consists of the off-label use of vasoconstrictive agents in combination with plasma expanders, a strategy that produces modest effects. Liver transplantation is the ultimate solution but is only an option in a minority of patients because contraindications to transplantation are common and organ availability is limited. Renal replacement therapy is a temporary option but is known to confer an extremely poor short-term prognosis in patients with HRS-AKI and at best serves as a bridge to liver transplantation for the minority of patients who are transplantation candidates. The high mortality rate associated with HRS-AKI in the United States is a reflection of the suboptimal standard of care. Improved therapeutic options to treat HRS-AKI are sought. Terlipressin is a drug approved in Europe for treatment of HRS-AKI and supported by recommendations for first-line therapy by some liver societies and experts around the world. This review article will discuss the substantial unmet medical need associated with HRS-AKI and the potential benefits if terlipressin was approved in the United States.
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Affiliation(s)
- Steven L. Flamm
- Division of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIL
| | - Kimberly Brown
- Division of Gastroenterology and HepatologyTransplant InstituteHenry Ford HospitalDetroitMI
| | - Hani M. Wadei
- Department of TransplantationMayo ClinicJacksonvilleFL
| | - Robert S. Brown
- Department of Medicine, Division of Gastroenterology and HepatologyWeill Cornell MedicineNew YorkNY
| | | | | | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology, and GastroenterologyPadua University HospitalPaduaItaly
| | - Fred Poordad
- University of Texas Health San Antonio, Texas Liver InstituteSan AntonioTX
| | - Sammy Saab
- Department of Internal Medicine and SurgeryDavid Geffen School of Medicine at University of California Los AngelesLos AngelesCA
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Simbrunner B, Trauner M, Reiberger T, Mandorfer M. Recent advances in the understanding and management of hepatorenal syndrome. Fac Rev 2021; 10:48. [PMID: 34131658 PMCID: PMC8170686 DOI: 10.12703/r/10-48] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Renal dysfunction occurs frequently in hospitalized patients with advanced chronic liver disease (ACLD)/cirrhosis and has profound prognostic implications. In ACLD patients with ascites, hepatorenal syndrome (HRS) may result from circulatory dysfunction that leads to reduced kidney perfusion and glomerular filtration rate (in the absence of structural kidney damage). The traditional subclassification of HRS has recently been replaced by acute kidney injury (AKI) type of HRS (HRS-AKI) and non-AKI type of HRS (HRS-NAKI), replacing the terms “HRS type 1” and “HRS type 2”, respectively. Importantly, the concept of absolute serum creatinine (sCr) cutoffs for diagnosing HRS was partly abandoned and short term sCr dynamics now may suffice for AKI diagnosis, which facilitates early treatment initiation that may prevent the progression to HRS-AKI or increase the chances of AKI/HRS-AKI reversal. Recent randomized controlled trials have established (a) the efficacy of (long-term) albumin in the prevention of complications of ascites (including HRS-AKI), (b) the benefits of transjugular intrahepatic portosystemic shunt placement in patients with recurrent ascites, and (c) the superiority of terlipressin over noradrenaline for the treatment of HRS-AKI in the context of acute-on-chronic liver failure. This review article aims to summarize recent advances in the understanding and management of HRS.
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Affiliation(s)
- Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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Sanchez LO, Francoz C. Global strategy for the diagnosis and management of acute kidney injury in patients with liver cirrhosis. United European Gastroenterol J 2021; 9:220-228. [PMID: 33337286 PMCID: PMC8259425 DOI: 10.1177/2050640620980713] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 11/18/2021] [Indexed: 12/18/2022] Open
Abstract
Acute kidney injury (AKI) is a clinical syndrome that complicates the course and worsens clinical outcomes in patients with chronic liver diseases. It is a common complication in hospitalised patients with liver cirrhosis, especially those with decompensated cirrhosis, associated with a high mortality rate. Considering its impact on patient prognosis, efforts should be made to diagnose and tailor therapeutic interventions for AKI at an early stage. In the past decade, a significant progress has been made to understand the key events and define major prognostic factors for the onset and progression of AKI in the cirrhotic population leading hepatologists to redefine the classic definition of hepatorenal syndrome and renal failure in this specific population.
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Affiliation(s)
- Lukas Otero Sanchez
- Department of Gastroenterology, Hepatopancreatology and Digestive OncologyUniversité Libre de BruxellesBrusselsBelgium
- Belgium Laboratory of Experimental Gastroenterology, Université Libre de BruxellesBrusselsBelgium
| | - Claire Francoz
- Department of Hepatology and Liver Intensive CareHospital BeaujonClichyFrance
- INSERM U1149Centre de Recherche sur L'InflammationParisFrance
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Abstract
Hepatorenal syndrome (HRS), the extreme manifestation of renal impairment in patients with cirrhosis, is characterized by reduction in renal blood flow and glomerular filtration rate. Hepatorenal syndrome is diagnosed when kidney function is reduced but evidence of intrinsic kidney disease, such as hematuria, proteinuria, or abnormal kidney ultrasonography, is absent. Unlike other causes of acute kidney injury (AKI), hepatorenal syndrome results from functional changes in the renal circulation and is potentially reversible with liver transplantation or vasoconstrictor drugs. Two forms of hepatorenal syndrome are recognized depending on the acuity and progression of kidney injury. The first represents an acute impairment of kidney function, HRS-AKI, whereas the second represents a more chronic kidney dysfunction, HRS-CKD (chronic kidney disease). In this review, we provide critical insight into the definition, pathophysiology, diagnosis, and management of hepatorenal syndrome.
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Affiliation(s)
- Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
| | - Pere Gines
- Liver Unit, Hospital Clinic, University of Barcelona IDIBAPS - CIBEReHD, Barcelona, Spain
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
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Velez JCQ, Therapondos G, Juncos LA. Reappraising the spectrum of AKI and hepatorenal syndrome in patients with cirrhosis. Nat Rev Nephrol 2019; 16:137-155. [PMID: 31723234 DOI: 10.1038/s41581-019-0218-4] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2019] [Indexed: 12/12/2022]
Abstract
The occurrence of acute kidney injury (AKI) in patients with end-stage liver disease constitutes one of the most challenging clinical scenarios in in-hospital and critical care medicine. Hepatorenal syndrome type 1 (HRS-1), which is a specific type of AKI that occurs in the context of advanced cirrhosis and portal hypertension, is associated with particularly high mortality. The pathogenesis of HRS-1 is largely viewed as a functional derangement that ultimately affects renal vasculature tone. However, new insights suggest that non-haemodynamic tubulo-toxic factors, such as endotoxins and bile acids, might mediate parenchymal renal injury in patients with cirrhosis, suggesting that concurrent mechanisms, including those traditionally associated with HRS-1 and non-traditional factors, might contribute to the development of AKI in patients with cirrhosis. Moreover, histological evidence of morphological abnormalities in the kidneys of patients with cirrhosis and renal dysfunction has prompted the functional nature of HRS-1 to be re-examined. From a clinical perspective, a diagnosis of HRS-1 guides utilization of vasoconstrictive therapy and decisions regarding renal replacement therapy. Patients with cirrhosis are at risk of AKI owing to a wide range of factors. However, the tools currently available to ascertain the diagnosis of HRS-1 and guide therapy are suboptimal. Short of liver transplantation, goal-directed haemodynamically targeted pharmacotherapy remains the cornerstone of treatment for this condition; improved understanding of the underlying pathogenic mechanisms might lead to better clinical outcomes. Here, we examine our current understanding of the pathophysiology of HRS-1 and existing challenges in its diagnosis and treatment.
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Affiliation(s)
- Juan Carlos Q Velez
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, LA, USA. .,Ochsner Clinical School, The University of Queensland, Brisbane, Australia.
| | - George Therapondos
- Department of Gastroenterology and Hepatology, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Luis A Juncos
- Division of Nephrology, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Renal Section, Department of Medicine, Central Arkansas Veterans Affairs Medical Center, Little Rock, AR, USA
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Palmer BF, Clegg DJ. The Use of Selected Urine Chemistries in the Diagnosis of Kidney Disorders. Clin J Am Soc Nephrol 2019; 14:306-316. [PMID: 30626576 PMCID: PMC6390907 DOI: 10.2215/cjn.10330818] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Urinary chemistries vary widely in both health and disease and are affected by diet, volume status, medications, and disease states. When properly examined, these tests provide important insight into the mechanism and therapy of various clinical disorders that are first detected by abnormalities in plasma chemistries. These tests cannot be interpreted in isolation, but instead require knowledge of key clinical information, such as medications, physical examination, and plasma chemistries, to include kidney function. When used appropriately and with knowledge of limitations, urine chemistries can provide important insight into the pathophysiology and treatment of a wide variety of disorders.
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Affiliation(s)
- Biff F Palmer
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Deborah Joy Clegg
- Department of Internal Medicine, University of California, Los Angeles School of Medicine, Los Angeles, California
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