Kidney Week Educational Symposia-Acute Kidney Dysfunction in Cirrhosis: A Case-Based Conversation about Diagnosis and Treatment

Video Transcription

Video Summary

The session introduces two nephrology experts presenting on acute kidney injury (AKI) and hepatorenal syndrome (HRS) in cirrhosis, using a case of a 55-year-old woman with decompensated alcoholic cirrhosis, edema, encephalopathy, and rising creatinine (0.8 to 1.5). Speakers emphasize that serum creatinine and standard eGFR equations often <em>overestimate</em> kidney function in cirrhosis due to sarcopenia and assay interference from high bilirubin; cystatin C and cirrhosis-specific equations (e.g., GRAIL) may be more accurate pre-transplant. AKI definitions in cirrhosis have evolved to align with general KDIGO criteria, now including <em>urine output</em> (shown to predict mortality even when creatinine does not rise).

Newer HRS-AKI criteria require cirrhosis <em>with ascites</em>, lack of improvement after appropriate (not automatic) fluid resuscitation within 24 hours, and no better primary cause—moving away from mandatory 48-hour albumin trials. Differential diagnosis includes hypovolemia, HRS, ATN, and less common intrinsic diseases. Fractional excretion of sodium is unreliable; urine NGAL can help distinguish ATN from HRS. Management stresses avoiding reflexive fluids/albumin, careful volume assessment, and vasoconstrictors (terlipressin or norepinephrine) with MAP targets, while monitoring for terlipressin-associated respiratory failure, often related to volume overload. Dialysis decisions should be individualized, often as a bridge to transplant.

Asset Subtitle

Moderator(s): Heather May

Presentation(s):

Introduction - Heather May
The Differential Dance: A Case-Based Discussion of Etiologies and Mechanisms of Acute Kidney Dysfunction in Cirrhosis - Neesh Pannu
Mastering Management: A Case-Based Discussion of Therapies for Acute Kidney Dysfunction in Cirrhosis - Mitra Nadim

Support is provided by an educational grant from Mallinckrodt Pharmaceuticals.

Meta Tag

Date 10/26/2024

Pathway 1 AKI and Critical Care

Pathway 2 Pharmacology

Session ID 495668

Session Type ES - Educational Symposium

Keywords

acute kidney injury (AKI) in cirrhosis

hepatorenal syndrome (HRS-AKI) criteria

serum creatinine limitations in cirrhosis

cystatin C and GRAIL equation

KDIGO AKI definition and urine output

differential diagnosis: HRS vs ATN vs hypovolemia

urine NGAL biomarker

vasoconstrictor therapy terlipressin/norepinephrine MAP targets

dialysis as bridge to liver transplant