Management of AKI in Patients with Cirrhosis

Abstract

Abstract Purpose of Review The development of acute failure of the kidneys in the context of decompensated cirrhosis represents one of the most challenging scenarios in clinical medicine due to the severity and complexity of the coexistence of those 2 illnesses. Thus, managing those cases can be cumbersome. Recent Findings While the state of advanced cirrhosis and portal hypertension can lead to a unique type of acute kidney injury (AKI)—hepatorenal syndrome type 1 (HRS-1)—a number of other etiologies can cause AKI, such as prerenal or cardiorenal insults, acute tubular injury, and other parenchymal entities. As a result, medical management of AKI in cirrhosis should be dictated by the driving cause of AKI. Summary Intravenous albumin is the preferred volume expander for hypovolemic states. Decongestive therapies are indicated in tense ascites-associated abdominal compartment syndrome and/or cardiorenal syndrome type 1. Vasoconstrictor therapy aimed to a specific rise in mean arterial pressure constitutes the cornerstone of the management of HRS-1. Most tubular causes of AKI are managed with supportive care, whereas other tubulointerstitial and glomerular conditions may warrant other interventions such as drug discontinuation, immunosuppression, or antimicrobial/antiviral therapy. Ultimately, AKI unresponsive to medical management may progress, and patients may ultimately necessitate renal replacement therapy (RRT) to sustain life. However, RRT must be carefully considered in this patient population taking in consideration eligibility for liver transplantation, life expectancy, risks and morbidity associated with RRT, and patients’ wishes and those of their families or support network.