Development of renal failure requiring renal replacement therapy (RRT) in the cirrhotic patient is a devastating complication. Survival without RRT is less than 10% on average at 6 months. However, it is now appreciated that all renal failure in this group of patients is not due solely to hepatorenal syndrome, and the cause of the renal failure affects the prognosis. This paper reviews the prognosis depending on cause and points out the difficulty in making the correct diagnosis. Provision of RRT is difficult in this group of patients due to hypotension and coagulopathy which is highly prevalent. Survival with RRT is still poor with only 30–60% of patients surviving to liver transplant. Provision of RRT should be offered as a bridge to patients awaiting liver transplant or those undergoing liver transplant evaluation. Provision of long-term RRT is usually not indicated in other cirrhotic patients who develop a need for RRT except as a trial to see if renal function will return. The decision between intermittent hemodialysis or continuous renal replacement therapy (CRRT) is usually based on the clinical characteristics of the patient. Neither has been demonstrated to be superior to the other, although CRRT may be better tolerated in the unstable patient. CRRT is clearly indicated in cases of fulminant hepatic failure as it does not raise intracranial pressure. Provision of intraoperative CRRT during liver transplant may be indicated to help control volume and electrolytes in those patients presenting for liver transplant with renal failure. Newer extracorporeal support systems, such as extracorporeal albumin dialysis (MARS) and fractional plasma separation and adsorption with hemodialysis (Prometheus), have recently been developed to provide both renal and liver support in this group of patients. These are still considered experimental, although the MARS system has been utilized to treat patients with hepatorenal syndrome, and is available outside the United States.

Keywords:
Liver cirrhosis, Renal replacement therapy, Renal failure
1.
Davis CL, Gonwa TA, Wilkinson AH: Pathophysiology of renal disease associated with liver disorders: implications for liver transplantation. Part I. Liver Transpl 2002;8:91–109.
2.
Gines P, Cardenas A, Arroyo V, Rodes J: Management of cirrhosis and ascites. N Engl J Med 2004;350:1646–1654.
3.
Wadei HM, Mai ML, Ahsan N, Gonwa TA: Hepatorenal syndrome: pathophysiology and management. Clin J Am Soc Nephrol 2006;1:1066–1079.
4.
Fraley DS, Burr R, Bernardini J, Angus D, Kramer DJ, Johnson JP: Impact of acute renal failure on mortality in end-stage liver disease with or without transplantation. Kidney Int 1998;54:518–524.
5.
Cholongitas E, Calvaruso V, Senzolo M, Patch D, Shaw S, O’Beirne J, Burroughs AK: RIFLE classification as predictive factor of mortality in patients with cirrhosis admitted to intensive care unit. J Gastroenterol Hepatol 2009;24:1639–1647.
6.
Cholongitas E, Senzolo M, Patch D, Shaw S, O’Beirne J, Burroughs AK: Cirrhotics admitted to intensive care unit: the impact of acute renal failure on mortality. Eur J Gastroenterol Hepatol 2009;21:744–750.
7.
Wadei HM, Geiger XJ, Cortese C, Mai ML, Kramer DJ, Rosser BG, Keaveny AP, Willingham DL, Ahsan N, Gonwa TA: Kidney allocation to liver transplant candidates with renal failure of undetermined etiology: role of percutaneous renal biopsy. Am J Transplant 2008;8:2618–2626.
8.
Martin-Llahi M, Guevara M, Torre A, Fagundes C, Restuccia T, Gilabert R, Sola E, Pereira G, Marinelli M, Pavesi M, Fernandez J, Rodes J, Arroyo V, Gines P: Prognostic importance of the cause of renal failure in patients with cirrhosis. Gastroenterology 2011;140:488–496, e484.
9.
Wong LP, Blackley MP, Andreoni KA, Chin H, Falk RJ, Klemmer PJ: Survival of liver transplant candidates with acute renal failure receiving renal replacement therapy. Kidney Int 2005;68:362–370.
10.
Jeyarajah DR, Gonwa TA, McBride M, Testa G, Abbasoglu O, Husberg BS, Levy MF, Goldstein RM, Klintmalm GB: Hepatorenal syndrome: combined liver kidney transplants versus isolated liver transplant. Transplantation 1997;64:1760–1765.
11.
Gonwa TA, McBride MA, Anderson K, Mai ML, Wadei H, Ahsan N: Continued influence of preoperative renal function on outcome of orthotopic liver transplant (OLTX) in the US: where will MELD lead us? Am J Transplant 2006;6:2651–2659.
12.
Davis CL, Feng S, Sung R, Wong F, Goodrich NP, Melton LB, Reddy KR, Guidinger MK, Wilkinson A, Lake J: Simultaneous liver-kidney transplantation: evaluation to decision making. Am J Transplant 2007;7:1702–1709.
13.
Ellis D, Avner ED: Renal failure and dialysis therapy in children with hepatic failure in the perioperative period of orthotopic liver transplantation. Clin Nephrol 1986;25:295–303.
14.
Wilkinson SP, Weston MJ, Parsons V, Williams R: Dialysis in the treatment of renal failure in patients with liver disease. Clin Nephrol 1977;8:287–292.
15.
Davenport A: Renal replacement therapy in the patient with acute brain injury. Am J Kidney Dis 2001;37:457–466.
16.
Davenport A, Bouman C, Kirpalani A, Skippen P, Tolwani A, Mehta RL, Palevsky PM: Delivery of renal replacement therapy in acute kidney injury: what are the key issues? Clin J Am Soc Nephrol 2008;3:869–875.
17.
Davenport A, Will EJ, Davidson AM: Improved cardiovascular stability during continuous modes of renal replacement therapy in critically ill patients with acute hepatic and renal failure. Crit Care Med 1993;21:328–338.
18.
Davenport A, Will EJ, Davison AM: Effect of renal replacement therapy on patients with combined acute renal and fulminant hepatic failure. Kidney Int Suppl 1993;41:S245–S251.
19.
De Vriese AS, Colardyn FA, Philippe JJ, Vanholder RC, De Sutter JH, Lameire NH: Cytokine removal during continuous hemofiltration in septic patients. J Am Soc Nephrol 1999;10:846–853.
20.
Navasa M, Follo A, Filella X, Jimenez W, Francitorra A, Planas R, Rimola A, Arroyo V, Rodes J: Tumor necrosis factor and interleukin-6 in spontaneous bacterial peritonitis in cirrhosis: relationship with the development of renal impairment and mortality. Hepatology 1998;27:1227–1232.
21.
Gonwa TA, Mai ML, Melton LB, Hays SR, Goldstein RM, Levy MF, Klintmalm GB: Renal replacement therapy and orthotopic liver transplantation: the role of continuous veno-venous hemodialysis. Transplantation 2001;71:1424–1428.
22.
Witzke O, Baumann M, Patschan D, Patschan S, Mitchell A, Treichel U, Gerken G, Philipp T, Kribben A: Which patients benefit from hemodialysis therapy in hepatorenal syndrome? J Gastroenterol Hepatol 2004;19:1369–1373.
23.
Detry O, Arkadopoulos N, Ting P, Kahaku E, Margulies J, Arnaout W, Colquhoun SD, Rozga J, Demetriou AA: Intracranial pressure during liver transplantation for fulminant hepatic failure. Transplantation 1999;67:767–770.
24.
Davenport A, Will EJ, Davison AM, Swindells S, Cohen AT, Miloszewski KJ, Losowsky MS: Changes in intracranial pressure during haemofiltration in oliguric patients with grade IV hepatic encephalopathy. Nephron 1989;53:142–146.
25.
Xia VW, Ghobrial RM, Du B, Chen T, Hu K-Q, Hiatt JR, Busuttil RW, Steadman RH: Predictors of hyperkalemia in the prereperfusion, early postreperfusion, and late postreperfusion periods during adult liver transplantation. Anesth Analg 2007;105:780–785.
26.
De Wolf A, Frenette L, Kang Y, Tang C: Insulin decreases the serum potassium concentration during the anhepatic stage of liver transplantation. Anesthesiology 1993;78:677–682.
27.
Townsend DR, Bagshaw SM, Jacka MJ, Bigam D, Cave D, Gibney RT: Intraoperative renal support during liver transplantation. Liver Transpl 2009;15:73–78.
28.
Cerda J, Tolwani A, Gibney N, Tiranathanagul K: Renal replacement therapy in special settings: extracorporeal support devices in liver failure. Semin Dial 2011;24:197–202.
29.
Mitzner SR, Klammt S, Peszynski P, Hickstein H, Korten G, Stange J, Schmidt R: Improvement of multiple organ functions in hepatorenal syndrome during albumin dialysis with the molecular adsorbent recirculating system. Ther Apher 2001;5:417–422.
30.
Mitzner SR, Stange J, Klammt S, Risler T, Erley CM, Bader BD, Berger ED, Lauchart W, Peszynski P, Freytag J, Hickstein H, Loock J, Lohr JM, Liebe S, Emmrich J, Korten G, Schmidt R: Improvement of hepatorenal syndrome with extracorporeal albumin dialysis MARS: results of a prospective, randomized, controlled clinical trial. Liver Transpl 2000;6:277–286.
31.
Khuroo MS, Farahat KL: Molecular adsorbent recirculating system for acute and acute-on-chronic liver failure: a meta-analysis. Liver Transpl 2004;10:1099–1106.
32.
Wong F, Raina N, Richardson R: Molecular adsorbent recirculating system is ineffective in the management of type 1 hepatorenal syndrome in patients with cirrhosis with ascites who have failed vasoconstrictor treatment. Gut 2010;59:381–386.
© 2012 S. Karger AG, Basel
2012
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.