Friday, November 19, 2010

ASN Live Update 2010: Cirrhosis and the Kidney

Th The Kidney in Liver Disease
Garcia-Tsao, MD
Take home points
1.      Pre liver transplant creatinine affects even post transplant survival of patient( based on data)
2.      Patients with Crt >1.0 pretransplant do worse post transplant
3.      Why is the serum crt low in cirrhosis( falsely): Decreased synthesis, malnutrition, less muscle mass, hyperbilirubenemia, and dilutational
4.      AKI can be divided in pre renal, renal and post renal causes in cirrhosis
5.      Pre renal causes are GI bleed, diarrhea usually due to lactulose, and hepatorenal syndrome(HRS)
6.      HRS is not volume responsive
7.      Intre renal causes  are ATN and GNs
8.      Post renal are rare
9.      20% of patients with cirrhosis in hospital have kidney injury( 19% is AKI and 1% is CKD). 68% of all are pre renal.  Of all pre renal most are volume responsive.
10.     In a study comparing pre renal ( diarrhea and GI bleed) causes and HRS, HRS has the lowest Na, lowest Mean arterial pressure and highest mortality
11.     Two things that make HRS worse worse splanchnic vasodilation and worse decrease in effective blood volume
12.     HRS-1 is aki, HRS2 is usually a chronic renal injury.  HRS -1 is a diagnosis of exclusion.  20% of AKI in cirrhosis, usually followed by infection and kidney is really not injured. 
13.     Diagnosis includes stopping all volume depleting agents first , looking for infection, giving IV Albumin 1g/kg qd or bid and if still no response in 48 hours, then check a cvp to see ifvolume replete and renal us, if all normal, then HRS Is diagnosed
14.     There is no data or studies on using bladder pressure in cirrhotics to date to discuss intra abdominal HTN

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