The renal management of acute hepatic failure and liver transplantation requires an understanding of the features of liver failure and the causes of liver graft dysfunction. The management of any underlying pathology in addition to supportive care is fundamental to successful management and a return to independent renal function. These issues are discussed particularly in relationship to a case history involving a patient presenting with acute fulminant liver failure secondary to a paracetamol overdose who was successfully treated by liver transplantation and continuous veno-venous haemodiafiltration. The liver can be successfully transplanted but acute renal failure is a severe complication post-transplantation. Its appearance can be predicted in patients with pre-transplant renal dysfunction, severe graft dysfunction, or both. It may be avoided through careful selection of transplant recipients and correct timing of transplantation. Prevention of renal failure, appropriate patient selection for transplantation and timely procurement of a donor organ are vital for best use of limited donor resources. Treatment success depends on patient and donor selection, skilled surgeons, careful post-operative care, and successful immunosuppression.

1.
Trey C, Davidson LS: The management of fulminant hepatic failure; in Popper H, Schaffner F (eds): Progress in Liver Disease. New York, Grune & Stratton, 1970, pp 282–298.
2.
Gimson AES, O’Grady J, Ede RJ, Portmann B, Williams R: Late onset hepatic failure: Clinical, serological and histological features. Hepatology 1986;6:288–294.
3.
Ede RJ, Williams R: Occurrence and management of cerebral oedema in liver failure; in Williams R (ed): Liver Failure. Edinburgh, Churchill Livingstone, 1986, pp 26–46.
4.
O’Grady JG, Wendon JA, Tan KC, et al: Liver transplantation after paracetamol overdose. BMJ 1991;303:221–223.
5.
Gazzard BG, Portmann B, Murray-Lyon IM, Williams R: Causes of death in fulminant hepatic failure and relationship to quantitative histological assessment of parenchymal damage. Q J Med 1975;176:615–626.
6.
O’Grady JG, Gimson AES, O’Brien CJ, Pucknell A, Hughes RD, Williams R: Controlled trials of charcoal hemoperfusion and prognostic factors in fulminant hepatic failure. Gastroenterology 1988;94:1186–1192.
7.
Clavien PA, Camargo CA Jr, Croxford R, Langer B, Levy GA, Greig PD: Definition and classification of negative outcomes in solid organ transplantation. Application in liver transplantation. Ann Surg 1994;220:109–120.
8.
Lütkes P, Lutz J, Daul A, Broelsch C, Phillip T, Heeman U: Continuous venovenous hemodialysis treatment in critically ill patients after transplantation. Kidney Int 1999;56 (suppl 72):S71–S74.
9.
Jones CH, Richardson D, Goutcher E, et al: Continuous venovenous high-flux dialysis in multiorgan failure: A 5-year single-center experience. Am J Kidney Dis 1998;31:227–233.
10.
Hawker F: The Liver: Critical Care Management. London, Saunders, 1993, pp 216–226.
11.
Ring-Larson H, Palazzo U: Renal failure in fulminant hepatic failure and terminal cirrhosis: A comparison between incidence, types and prognosis. Gut 1981;22:585–591.
12.
Ring-Larson H, Henriksen JH, Christensen NJ: Increased sympathetic activity in cirrhosis. N Engl J Med 1983;308:1029–1030.
13.
Panos MZ, Anderson JV, Forbes A, et al: Human atrial natriuretic factor and renin-aldosterone in paracetamol-induced fulminant hepatic failure. Gut 1991;32:85–89.
14.
Busuttil RW, Colonna JO 2nd, Hiatt JR, Brems JJ, Khoury G, Goldstein LI, Quinones-Baldrich WJ, Abdul-Rasool IH, Ramming KP: The first 100 liver transplants at UCLA. Ann Surg 1987;206:387–402.
15.
Kirby RM, McMaster P, Clements D, Hubscher SG, Angrisani L, Sealey M, Gunson BK, Salt PJ, Buckels JA, Adams DH, et al: Orthotopic liver transplantation: Postoperative complications and their management. Br J Surg 1987;74:3–11.
16.
Bilbao I, Charco R, Balsells J, Lazaro JL, Hidalgo E, Llopart L, Murio E, Margarit C: Risk factors for acute renal failure requiring dialysis after liver transplantation. Clin Transplant 1998;12:123–129.
17.
Mendoza A, Fernandez F, Mutimer DJ: Liver transplantation for fulminant hepatic failure: Importance of renal failure. Transplant Int 1997;10:55–60.
18.
Ronco C, Bellomo R, Homel P, Brendolan A, Dan M, Piccinni P, Greca GL: Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: A prospective randomised trial. Lancet 2000;356:26–30.
19.
Davenport A, Will EJ, Davison AM: Continuous vs. intermittent forms of haemofiltration and/or dialysis in the management of acute renal failure in patients with defective cerebral autoregulation at risk of cerebral oedema. Contrib Nephrol. Basel, Karger, 1991, vol 93, pp 225–233.
20.
Davenport A, Will EJ, Davison AM: Early changes in intracranial pressure during haemofiltration treatment in patients with grade 4 hepatic encephalopathy and acute oliguric renal failure. Nephrol Dial Transplant 1990;5:192–198.
21.
Hanid MA, Davies M, Mellon PJ, et al: Clinical monitoring of intracranial pressure in fulminant hepatic failure. Gut 1980;21:866–869.
22.
Canalese J, Gimson AES, Davis C, Mellon PJ, Davis M, Williams R: Controlled trial of dexamethasone and mannitol for the cerebral oedema of fulminant hepatic failure. Gut 1982;23:625–629.
23.
Cooli Jalan R, Damink SW, Deutz NE, Lee A, Hayes PC: Moderate hypothermia for uncontrolled intracranial hypertension in acute liver failure. Lancet 1999;354:1164–1168.
24.
Davenport A, Will EJ, Davison AM: Effect of posture on intracranial pressure and cerebral perfusion pressure in patients with fulminant hepatic and renal failure after acetaminophen self-poisoning. Crit Care Med 1990;18:286–289.
25.
Kierdorf HP, Leue C, Arns S: Lactate- or bicarbonate-buffered solutions in continuous extracorporeal renal replacement therapies. Kidney Int Suppl 1999;72:S32–S36.
26.
Zimmerman D, Cotman P, Ting R, Karanicolas S, Tobe SW: Continuous veno-venous haemodialysis with a novel bicarbonate dialysis solution: Prospective cross-over comparison with a lactate-buffered solution. Nephrol Dial Transplant 1999;14:2387–2391.
27.
Meier-Kriesche HU, Finkel KW, Gitomer JJ, DuBose TD Jr: Unexpected severe hypocalcemia during continuous venovenous hemodialysis with regional citrate anticoagulation. Am J Kidney Dis 1999;33:8.
28.
Davenport A, Will EJ, Davison AM: Comparison of the use of standard heparin and prostacyclin anticoagulation in spontaneous and pump-driven extracorporeal circuits in patients with combined acute renal and hepatic failure. Nephron 1994;66:431–437.
29.
Davenport A, Will EJ, Davison AM: The effect of prostacyclin on intracranial pressure in patients with acute hepatic and renal failure. Clin Nephrol 1991;35:151–157.
30.
Merion RM: Prostaglandins in liver transplantation. Adv Exp Med Biol 1997;433:13–18.
31.
Greig PD, Woolf GM, Sinclair SB, Abecassis M, Strasberg SM, Taylor BR, Blendis LM, Superina RA, Glynn MF, Langer B, et al: Treatment of primary liver graft nonfunction with prostaglandin E1. Transplantation 1989;48:447–453.
32.
Ash SR, Kuczek T, Steczko J, Blake DE, Gingrich CH: Randomized clinical trials of liver dialysis in treatment of hepatic failure and hepatorenal failure. J Am Soc Nephrol 2000;11:173A.
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