The Patient with Severe Co-morbidities: Renal Failure

  • Andrew Disque
  • Joseph Meltzer


Renal injury and failure is a frequent and potentially devastating complication of liver cirrhosis and patients undergoing liver transplantation [1]. When renal injury progresses to failure the prognosis for patients with concomitant cirrhosis is poor [2]. Preoperative renal dysfunction is also associated with significantly worsened outcomes in patients who undergo liver transplantation [3]. In 2002, the United Network for Organ Sharing (UNOS) modification to the Model for End Stage Liver Disease (MELD) scoring system was implemented for prioritizing patients on the liver transplant waiting list due to its ability to predict survival for patients with end-stage liver disease [4]. It replaced the Child-Pugh scoring system. Both UNOS and Eurotransplant now use the MELD score for allocating organs to patients awaiting liver transplantation. Serum creatinine, a marker of renal function, is one of only three variables used in the MELD score, highlighting the importance of...


Renal insufficiency Chronic kidney disease Acute kidney injury Hepatorenal syndrome Renal replacement therapy Dialysis 


  1. 1.
    Gines P, Schrier RW. Renal failure in cirrhosis. N Engl J Med. 2009;361(13):1279–90.CrossRefGoogle Scholar
  2. 2.
    Nair S, Verma S, Thuluvath PJ. Pretransplant renal function predicts survival in patients undergoing orthotopic liver transplantation. Hepatology. 2002;35(5):1179–85.CrossRefGoogle Scholar
  3. 3.
    Gonwa TA, Klintmalm GB, Levy M, Jennings LS, Goldstein RM, Husberg BS. Impact of pretransplant renal function on survival after liver transplantation. Transplantation. 1995;59(3):361–5.CrossRefGoogle Scholar
  4. 4.
    Wiesner R, Edwards E, Freeman R, et al. Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology. 2003;124(1):91–6.CrossRefGoogle Scholar
  5. 5.
    Kamath PS, Kim WR. The model for end-stage liver disease (MELD). Hepatology. 2007;45(3):797–805.CrossRefGoogle Scholar
  6. 6.
    Thadhani R, Pascual M, Bonventre JV. Acute renal failure. N Engl J Med. 1996;334(22):1448–60.CrossRefGoogle Scholar
  7. 7.
    Kellum JA, Levin N, Bouman C, Lameire N. Developing a consensus classification system for acute renal failure. Curr Opin Crit Care. 2002;8(6):509–14.CrossRefGoogle Scholar
  8. 8.
    Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11(2):R31.CrossRefPubMedGoogle Scholar
  9. 9.
    Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P. Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004;8(4):R204–12.CrossRefPubMedGoogle Scholar
  10. 10.
    Cholongitas E, Calvaruso V, Senzolo M, et al. RIFLE classification as predictive factor of mortality in patients with cirrhosis admitted to intensive care unit. J Gastroenterol Hepatol. 2009;24(10):1639–47.CrossRefGoogle Scholar
  11. 11.
    Schrier RW, Wang W. Acute renal failure and sepsis. N Engl J Med. 2004;351(2):159–69.CrossRefGoogle Scholar
  12. 12.
    Meltzer J, Brentjens TE. Renal failure in patients with cirrhosis: hepatorenal syndrome and renal support strategies. Curr Opin Anaesthesiol. 2010;23(2):139–44.CrossRefGoogle Scholar
  13. 13.
    Martin PY, Gines P, Schrier RW. Nitric oxide as a mediator of hemodynamic abnormalities and sodium and water retention in cirrhosis. N Engl J Med. 1998;339(8):533–41.CrossRefGoogle Scholar
  14. 14.
    Arroyo V, Gines P, Gerbes AL, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club. Hepatology. 1996;23(1):164–76.CrossRefGoogle Scholar
  15. 15.
    Schrier RW, Arroyo V, Bernardi M, Epstein M, Henriksen JH, Rodes J. Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology. 1988;8(5):1151–7.CrossRefGoogle Scholar
  16. 16.
    Salerno F, Gerbes A, Gines P, Wong F, Arroyo V. Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis. Gut. 2007;56(9):1310–8.PubMedCentralPubMedGoogle Scholar
  17. 17.
    Alessandria C, Ozdogan O, Guevara M, et al. MELD score and clinical type predict prognosis in hepatorenal syndrome: relevance to liver transplantation. Hepatology. 2005;41(6):1282–9.CrossRefGoogle Scholar
  18. 18.
    Martin-Llahi M, Pepin MN, Guevara M, et al. Terlipressin and albumin vs albumin in patients with cirrhosis and hepatorenal syndrome: a randomized study. Gastroenterology. 2008;134(5):1352–9.CrossRefGoogle Scholar
  19. 19.
    Angeli P, Gines P, Wong F, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. Gut. 2015;64(4):531–7.CrossRefGoogle Scholar
  20. 20.
    Wagener G, Brentjens TE. Anesthetic concerns in patients presenting with renal failure. Anesthesiol Clin. 2010;28(1):39–54.CrossRefGoogle Scholar
  21. 21.
    Sherman DS, Fish DN, Teitelbaum I. Assessing renal function in cirrhotic patients: problems and pitfalls. Am J Kidney Dis. 2003;41(2):269–78.CrossRefGoogle Scholar
  22. 22.
    Hojs R, Bevc S, Ekart R, Gorenjak M, Puklavec L. Serum cystatin C as an endogenous marker of renal function in patients with mild to moderate impairment of kidney function. Nephrol Dial Transplant. 2006;21(7):1855–62.CrossRefGoogle Scholar
  23. 23.
    Wagener G, Minhaz M, Mattis FA, Kim M, Emond JC, Lee HT. Urinary neutrophil gelatinase-associated lipocalin as a marker of acute kidney injury after orthotopic liver transplantation. Nephrol Dial Transplant. 2011;26(5):1717–23.CrossRefPubMedGoogle Scholar
  24. 24.
    Verna EC, Brown RS, Farrand E, et al. Urinary neutrophil gelatinase-associated lipocalin predicts mortality and identifies acute kidney injury in cirrhosis. Dig Dis Sci. 2012;57(9):2362–70.CrossRefPubMedGoogle Scholar
  25. 25.
    Matuszkiewicz-Rowinska J, Malyszko J, Wieliczko M. Renal support during liver transplantation: when to consider it? Transplant Proc. 2013;45(9):3157–62.CrossRefGoogle Scholar
  26. 26.
    Schortgen F, Lacherade JC, Bruneel F, et al. Effects of hydroxyethylstarch and gelatin on renal function in severe sepsis: a multicentre randomised study. Lancet. 2001;357(9260):911–6.CrossRefGoogle Scholar
  27. 27.
    Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004;350(22):2247–56.CrossRefGoogle Scholar
  28. 28.
    Tandon P, Garcia-Tsao G. Bacterial infections, sepsis, and multiorgan failure in cirrhosis. Semin Liver Dis. 2008;28(1):26–42.CrossRefGoogle Scholar
  29. 29.
    Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–77.CrossRefGoogle Scholar
  30. 30.
    The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301–8.CrossRefGoogle Scholar
  31. 31.
    Finfer S, Chittock DR, SY S, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283–97.CrossRefPubMedGoogle Scholar
  32. 32.
    Tsai MH, Peng YS, Chen YC, et al. Adrenal insufficiency in patients with cirrhosis, severe sepsis and septic shock. Hepatology. 2006;43(4):673–81.CrossRefGoogle Scholar
  33. 33.
    Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36(1):296–327.CrossRefGoogle Scholar
  34. 34.
    Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh J. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Lancet. 2000;356(9248):2139–43.CrossRefPubMedGoogle Scholar
  35. 35.
    Friedrich JO, Adhikari N, Herridge MS, Beyene J. Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med. 2005;142(7):510–24.CrossRefGoogle Scholar
  36. 36.
    Lassnigg A, Donner E, Grubhofer G, Presterl E, Druml W, Hiesmayr M. Lack of renoprotective effects of dopamine and furosemide during cardiac surgery. J Am Soc Nephrol. 2000;11(1):97–104.Google Scholar
  37. 37.
    Ho KM, Sheridan DJ. Meta-analysis of frusemide to prevent or treat acute renal failure. BMJ. 2006;333(7565):420.CrossRefPubMedGoogle Scholar
  38. 38.
    Moreau R, Lebrec D. Acute renal failure in patients with cirrhosis: perspectives in the age of MELD. Hepatology. 2003;37(2):233–43.CrossRefGoogle Scholar
  39. 39.
    Sanyal AJ, Boyer T, Garcia-Tsao G, et al. A randomized, prospective, double-blind, placebo-controlled trial of terlipressin for type 1 hepatorenal syndrome. Gastroenterology. 2008;134(5):1360–8.CrossRefPubMedGoogle Scholar
  40. 40.
    Wagener G, Kovalevskaya G, Minhaz M, Mattis F, Emond JC, Landry DW. Vasopressin deficiency and vasodilatory state in end-stage liver disease. J Cardiothorac Vasc Anesth. 2011;25(4):665–70.CrossRefPubMedGoogle Scholar
  41. 41.
    Wong F, Pantea L, Sniderman K. Midodrine, octreotide, albumin, and TIPS in selected patients with cirrhosis and type 1 hepatorenal syndrome. Hepatology. 2004;40(1):55–64.CrossRefGoogle Scholar
  42. 42.
    Brensing KA, Textor J, Perz J, et al. Long term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase II study. Gut. 2000;47(2):288–95.CrossRefPubMedGoogle Scholar
  43. 43.
    Phua J, Lee KH. Liver support devices. Curr Opin Crit Care. 2008;14(2):208–15.CrossRefGoogle Scholar
  44. 44.
    Davis CL, Feng S, Sung R, et al. Simultaneous liver-kidney transplantation: evaluation to decision making. Am J Transplant. 2007;7(7):1702–9.CrossRefGoogle Scholar
  45. 45.
    Kusudo K, Ishii K, Rahman M, et al. Blood flow-dependent changes in intrarenal nitric oxide levels during anesthesia with halothane or sevoflurane. Eur J Pharmacol. 2004;498(1–3):267–73.CrossRefGoogle Scholar
  46. 46.
    Gentz BA, Malan TP Jr. Renal toxicity with sevoflurane: a storm in a teacup? Drugs. 2001;61(15):2155–62.CrossRefGoogle Scholar
  47. 47.
    Clavien PA, Petrowsky H, DeOliveira ML, Graf R. Strategies for safer liver surgery and partial liver transplantation. N Engl J Med. 2007;356(15):1545–59.CrossRefGoogle Scholar
  48. 48.
    Schroeder RA, Kuo PC. Pro: low central venous pressure during liver transplantation—not too low. J Cardiothorac Vasc Anesth. 2008;22(2):311–4.CrossRefGoogle Scholar
  49. 49.
    Massicotte L, Beaulieu D, Thibeault L. Con: low central venous pressure during liver transplantation. J Cardiothorac Vasc Anesth. 2008;22(2):315–7.CrossRefGoogle Scholar
  50. 50.
    Nahas GG, Sutin KM, Fermon C, et al. Guidelines for the treatment of acidaemia with THAM. Drugs. 1998;55(2):191–224.CrossRefGoogle Scholar
  51. 51.
    Solus-Biguenet H, Fleyfel M, Tavernier B, et al. Non-invasive prediction of fluid responsiveness during major hepatic surgery. Br J Anaesth. 2006;97(6):808–16.CrossRefGoogle Scholar
  52. 52.
    Biais M, Nouette-Gaulain K, Roullet S, Quinart A, Revel P, Sztark F. A comparison of stroke volume variation measured by Vigileo/FloTrac system and aortic Doppler echocardiography. Anesth Analg. 2009;109(2):466–9.CrossRefGoogle Scholar
  53. 53.
    Agopian VG, Dhillon A, Baber J, et al. Liver transplantation in recipients receiving renal replacement therapy: outcomes analysis and the role of intraoperative hemodialysis. Am J Transplant. 2014;14(7):1638–47.CrossRefGoogle Scholar
  54. 54.
    Goren O, Matot I. Perioperative acute kidney injury. Br J Anaesth. 2015;115(Suppl 2):ii3–14.CrossRefGoogle Scholar
  55. 55.
    Townsend DR, Bagshaw SM, Jacka MJ, Bigam D, Cave D, Gibney RT. Intraoperative renal support during liver transplantation. Liver Transpl. 2009;15(1):73–8.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Anesthesiology and Perioperative MedicineDavid Geffen School of Medicine, University of California at Los AngelesLos AngelesUSA
  2. 2.Division of Critical Care, Department of Anesthesiology and Perioperative MedicineDavid Geffen School of Medicine, University of California at Los AngelesLos AngelesUSA

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