Kidney Week Educational Symposia-Current and Future Approaches to the Diagnostic Assessment and Management of AKI in Patients with Cirrhosis

Video Transcription

Video Summary

The session introduced the growing global and U.S. burden of cirrhosis and highlighted that acute kidney injury (AKI) is now detected in up to ~40% of hospitalized patients with cirrhosis using sensitive definitions. Dr. Chirag Parikh reviewed AKI etiologies in cirrhosis—prerenal azotemia (often volume-responsive), acute tubular necrosis (ATN), and hepatorenal syndrome (HRS-AKI)—noting that distinguishing HRS from ATN is difficult yet crucial because treatments differ (albumin/volume for prerenal, vasoconstrictors for HRS, supportive care/dialysis for ATN). He emphasized cirrhosis as a state of impaired renal autoregulation where patients can shift along a spectrum from functional hypoperfusion (HRS) to structural injury (ATN). He presented evidence that biomarkers can improve early triage: urine NGAL helps discriminate ATN (highest) from prerenal (lowest) with HRS intermediate; very low FENa (often <0.2%) may support HRS; urine microscopy (muddy brown casts, tubular epithelial cells) supports ATN. He urged labs to report low urine sodium values to enable accurate low FENa calculations.<br /><br />Dr. Florence Wong focused on evidence-based HRS-AKI management: identify and treat triggers (especially infection), stop diuretics/beta-blockers when appropriate, give an albumin challenge, then start vasoconstrictor therapy early in eligible patients while expediting liver transplant evaluation. Terlipressin plus albumin is most used and improves HRS reversal versus placebo, but carries respiratory failure risk, particularly in high-grade ACLF and in patients with hypoxia; it is not recommended when creatinine >5 mg/dL or O2 saturation <90%. Norepinephrine may be similarly effective but requires close monitoring. Future directions include safer partial V1 agonists and combinations (e.g., serelaxin) to enhance renal perfusion.

Asset Subtitle

Moderators: Kathleen Liu

Introduction - Kathleen Liu
Current Approach to the Diagnostic Evaluation of Patients with AKI and Cirrhosis - Chirag Parikh
Evidence-Based Management of Hepatorenal Syndrome with AKI - Florence Wong

Support is provided by an educational grant from Mallinckrodt Pharmaceuticals.

Meta Tag

Date 11/4/2022

Pathway 1 AKI and Critical Care

Session ID 438058

Session Type ES - Educational Symposium

Keywords

cirrhosis burden

acute kidney injury in cirrhosis

hepatorenal syndrome (HRS-AKI)

acute tubular necrosis (ATN)

prerenal azotemia

urine NGAL biomarker

fractional excretion of sodium (FENa)

terlipressin plus albumin

vasoconstrictor therapy and liver transplant evaluation