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The evolving concept of acute kidney injury in patients with cirrhosis

Nature Reviews Gastroenterology & Hepatology volume 12, pages 711–719 (2015)Cite this article

Subjects

Key Points

  • Acute kidney injury (AKI) in cirrhosis consists of a spectrum of diseases, some related to abnormalities in renal function, whereas others are related to renal damage

  • The International Club of Ascites defined AKI in cirrhosis by small changes in serum creatinine and has defined staging, progression and response to treatment

  • Acute or type 1 hepatorenal syndrome (HRS) is now known as HRS-AKI, whereas chronic type 2 HRS is now known as HRS chronic kidney disease

  • The new AKI definition allows patients with persistent doubling of serum creatinine despite albumin and diuretic withdrawal who otherwise fulfil the diagnostic criteria for hepatorenal syndrome to receive pharmacotherapy

  • The use of biomarkers of renal functional changes and structural damage might enhance our ability to assess risk, diagnose AKI and provide a prognosis for patients

  • New knowledge of the pathophysiology of AKI in patients with liver cirrhosis could lead to further refinement of our definition of AKI for cirrhosis in the future

Abstract

Renal dysfunction is prevalent in patients with advanced cirrhosis and decompensation. The presence of type 1 hepatorenal syndrome (HRS) has traditionally been defined by a set of stringent criteria based on serum creatinine levels. These diagnostic criteria have been found to be too stringent to be widely applicable to patients with cirrhosis, leading to underdiagnosis of renal failure in this population. Acute kidney injury (AKI) has now been proposed to characterize renal dysfunction in patients with cirrhosis and is defined as an increase in serum creatinine by 0.3 mg/dl in <48 h or an increase in serum creatinine by 50% from a stable baseline reading within 3 months. Type 1 HRS is renamed HRS-AKI. Stage 1 AKI is defined by 0.3 mg/dl serum creatinine or a 50% increase, stages 2 and 3 AKI are defined by a two-fold and three-fold increase in serum creatinine levels, respectively. Data collected so far suggests that even stage 1 AKI is associated with worse prognosis in patients with cirrhosis. The progression of AKI usually indicates substantially worse outcomes. A panel of biomarkers, including inflammatory markers, are envisaged to complement and enhance our current diagnostic criteria in the future and provide aetiology of the AKI.

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Figure 1: Spectrum of renal diseases in cirrhosis.
Figure 2: Pathogenetic mechanism of acute kidney injury in cirrhosis.
Figure 3: Progression of stage of acute kidney injury is associated with significantly worse survival.
Figure 4: Proposed algorithm for the management of patients with cirrhosis who present acute kidney injury.
Figure 5: A schematic representation of the evolution of the diagnosis of renal dysfunction in cirrhosis.

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  1. Department of Medicine, Division of Gastroenterology, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto, M5G2C4, ON, Canada

    Florence Wong

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Correspondence to Florence Wong.

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Wong, F. The evolving concept of acute kidney injury in patients with cirrhosis. Nat Rev Gastroenterol Hepatol 12, 711–719 (2015). https://doi.org/10.1038/nrgastro.2015.174

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