Division of Gastroenterology, Department of Medicine, 9th floor, Room 222, Eaton Wing, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G2C4, Canada.
Hepatol Int. 2020 Mar;14(2):167-179. doi: 10.1007/s12072-020-10018-0. Epub 2020 Mar 3.
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.
在肝硬化中，肾功能障碍的定义和诊断标准最近发生了重大变化。急性肾损伤（AKI）的定义是血清肌酐在<48 小时内升高≥26.4µmol/L（0.3mg/dL）。其严重程度通过分期定义。慢性肾脏病（CKD）的定义是估计肾小球滤过率（GFR）降低至<60mL/min 超过 3 个月。AKI 和 CKD 均可与肾灌注减少相关，即所谓的功能性肾衰竭；或者由于肾实质的结构损伤。血流动力学变化和过度炎症是使肝硬化患者易发生功能性 AKI 的病理生理过程。导致血流动力学进一步紊乱或促进进一步炎症的事件，如细菌感染，将促使 AKI 的发生。治疗从去除潜在的诱发因素和补充血容量开始。白蛋白是首选的容量扩充剂，因为它具有多种特性，可以显著减少炎症程度并改善血容量。对白蛋白输注无反应的患者应接受血管收缩剂治疗，如特利加压素，根据患者的血压反应进行滴定，约 50%的患者有效。所有有肾功能和肝功能障碍的患者都应评估肝移植，以肾脏替代治疗作为桥接。联合肝肾移植有指南可循。未来关于 AKI 的研究应评估血管收缩剂对最近标准定义的肾功能的影响，并开发生物标志物来识别易感患者，以便早期进行治疗。
