Chronic renal dysfunction in cirrhosis: A new frontier in hepatology

Abstract

Chronic kidney disease (CKD) in patients with liver cirrhosis has become a new frontier in hepatology. In recent years, a sharp increase in the diagnosis of CKD has been observed among patients with cirrhosis. The rising prevalence of risk factors, such as diabetes, hypertension and nonalcoholic fatty liver disease, appears to have contributed significantly to the high prevalence of CKD. Moreover, the diagnosis of CKD in cirrhosis is now based on a reduction in the estimated glomerular filtration rate of < 60 mL/min over more than 3 mo. This definition has resulted in a better differentiation of CKD from acute kidney injury (AKI), leading to its greater recognition. It has also been noted that a significant proportion of AKI transforms into CKD in patients with decompensated cirrhosis. CKD in cirrhosis can be structural CKD due to kidney injury or functional CKD secondary to circulatory and neurohormonal imbalances. The available literature on combined cirrhosis-CKD is extremely limited, as most attempts to assess renal dysfunction in cirrhosis have so far concentrated on AKI. Due to problems related to glomerular filtration rate estimation in cirrhosis, the absence of reliable biomarkers of CKD and technical difficulties in performing renal biopsy in advanced cirrhosis, CKD in cirrhosis can present many challenges for clinicians. With combined hepatorenal dysfunctions, fluid mobilization becomes problematic, and there may be difficulties with drug tolerance, hemodialysis and decision-making regarding the need for liver vs simultaneous liver and kidney transplantation. This paper offers a thorough overview of the increasingly known CKD in patients with cirrhosis, with clinical consequences and difficulties occurring in the diagnosis and treatment of such patients.

Keywords: Acute kidney injury; Cirrhosis; Chronic kidney disease; Renal failure; Hepatorenal syndrome; Renal function

Core Tip: The current definition of chronic kidney disease (CKD) in patients with liver cirrhosis is based on a 3-mo decline in the glomerular filtration rate of < 60 mL/min, and it may be structural or functional CKD, depending on the presence or absence of kidney injury. Emerging data show that the incidence of CKD has risen dramatically in patients with cirrhosis over the last decade. The main reasons behind the increased prevalence of CKD appear to be a growing recognition of this condition and a rising trend in the prevalence of diabetes, hypertension and nonalcoholic fatty liver disease. This paper offers a detailed overview of CKD in patients with cirrhosis, including the clinical implications and difficulties clinicians may face with regard to diagnosis and treatment.