Kidney Week 2025 Annual Meeting-Controversies in the Management of Kidney Dysfunction in Advanced Liver Disease

Video Transcription

Video Summary

The session focused on kidney dysfunction in advanced cirrhosis and its implications for prognosis and transplantation. Speakers emphasized that serum creatinine is a flawed marker in cirrhosis: it frequently overestimates GFR due to sarcopenia, reduced hepatic creatine synthesis, volume issues, and assay interference, and it rises late in AKI. This leads to under-recognized CKD and delayed AKI detection, especially in the sickest patients. Newer approaches include cirrhosis-specific eGFR equations (e.g., GRAIL) and increased use of cystatin C, which is less muscle-dependent and may better predict outcomes; the creatinine–cystatin “delta” may also reflect frailty and risk. Injury biomarkers such as NGAL can help distinguish functional AKI/HRS from ATN and may guide earlier, more tailored therapy.<br /><br />Hepatorenal syndrome (HRS) was reviewed as a high-mortality complication driven by splanchnic vasodilation, neurohormonal activation, and often cirrhotic cardiomyopathy. Diagnostic criteria are evolving: 2024 guidance deemphasizes mandatory 48-hour albumin trials and supports earlier clinical diagnosis. Treatment updates highlighted terlipressin plus albumin as the best-studied vasoconstrictor strategy (30–50% reversal), with important risks of respiratory failure—especially in ACLF grade 3—requiring careful patient selection and monitoring.<br /><br />Transplant policy discussions covered simultaneous liver–kidney (SLK) and the post-2017 “safety net.” SLK numbers have stabilized, while kidney-after-liver transplants have increased, often for HRS. Key concerns include inaccurate GFR estimation, arbitrary cutoffs, and patients too sick to survive to safety-net eligibility. Finally, dialysis in cirrhosis should be framed as optimization for transplant when appropriate; “futility” is hard to predict, and time-limited trials require clearer goals and multidisciplinary alignment.

Asset Subtitle

Moderator(s): Xingxing Cheng, Kevin Regner

Presentation(s):

Serum Creatinine: Strengths and Limitations in Liver Disease - Giuseppe Cullaro
Treatment of Hepatorenal Syndrome: Implications for Liver and Kidney Transplantation - Andrew Allegretti
SLKT and Safety Net Listing: Implications for Nephrology Professionals - Sumeet Asrani
Kidney Replacement Therapy in Cirrhosis: Difficult Discussions - Mitra Nadim

Meta Tag

Date 11/6/2025

Pathway 1 Kidney Transplantation

Pathway 2 AKI and Critical Care

Session ID 505243

Keywords

advanced cirrhosis

kidney dysfunction

serum creatinine limitations

sarcopenia

GFR overestimation

acute kidney injury in cirrhosis

cirrhosis-specific eGFR (GRAIL)

cystatin C

creatinine–cystatin delta

frailty risk stratification

NGAL biomarker

hepatorenal syndrome (HRS)

terlipressin plus albumin

simultaneous liver–kidney transplant (SLK)

post-2017 safety net policy