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Introduction At present, there are still few data on the prevalence, clinical impact and treatment of cirrhosis with chronic kidney disease (CKD).
However, in the past decade, the incidence of CKD in patients with liver cirrhosis has risen sharply.
The main reason for the increase in the prevalence of CKD seems to be the increasing awareness of this disease, as well as the increasing prevalence of diabetes (DM), hypertension, and non-alcoholic fatty liver disease (NAFLD).
This review provides a detailed overview of liver cirrhosis with CKD, including its clinical impact and the difficulties that clinicians may face in diagnosis and treatment.
The definition and classification of liver cirrhosis with CKD The current definition of liver cirrhosis with CKD is: the estimated glomerular filtration rate (eGFR) is reduced to <60 mL/min and more than 3 according to the modified kidney disease diet (MDRD)-6 formula month.
Currently, the diagnosis of CKD does not require conclusive evidence of kidney damage, such as proteinuria, hematuria, renal imaging or pathological abnormalities.
The organization to improve the prognosis of global kidney disease has divided CKD into structural and functional categories based on whether there is kidney damage.
Patients with liver cirrhosis may have some risk factors for structural CKD, such as DM, NAFLD and atherosclerosis.
In addition, the continuous renal vasoconstriction of functional CKD can lead to structural changes, turning it into structural CKD.
The clinical impact of cirrhosis with CKD CKD can affect the clinical manifestations, complications, treatment strategies and outcomes of patients with liver cirrhosis in many ways.
In patients with liver cirrhosis, CKD may cause ascites and edema in various ways, such as nephrogenic ascites, chronic fluid overload, hypoproteinemia and cardiomyopathy.
Due to a variety of complex hemostatic abnormalities, patients with liver and kidney dysfunction may have a higher bleeding tendency.
CKD is an independent risk factor for cardiovascular death and can aggravate anemia caused by cirrhosis.
Both CKD and liver cirrhosis can cause immunosuppression, leading to an increased risk of infection.
Patients with liver cirrhosis and CKD appear to have an increased risk of malignant tumors.
After adjusting for many possible confounding factors, the reduction in GFR has been shown to be independently associated with the increased risk of renal cell carcinoma and urothelial carcinoma.
CKD is associated with increased mortality of liver cancer, kidney cancer and urothelial cancer.
Since liver and kidney diseases can independently cause anorexia, anemia, ascites, bleeding tendency, and encephalopathy, it is often difficult to determine which disease causes the above symptoms in patients with cirrhosis and CKD.
This may make it difficult to determine the best treatment options (such as the need for renal replacement therapy).
Liver cirrhosis with CKD is associated with adverse outcomes and increased frequency of complications.
Wong et al.
found that compared with patients with cirrhosis without CKD, patients with cirrhosis and CKD had a higher incidence of acute kidney injury (AKI), the need for dialysis, and the 30-day mortality rate.
A study by Bassegoda et al.
showed that compared with patients without CKD, patients with liver cirrhosis and CKD have a higher risk of AKI, refractory ascites, bacterial infection, and liver transplantation (LT) requirements.
In addition, liver cirrhosis is independently associated with the adverse outcomes of CKD patients.
Diagnosis and evaluation of cirrhosis with CKD The diagnosis of cirrhosis with CKD is based on GFR (the expert panel recommends MDRD-6 to evaluate eGFR).
Abnormal urinalysis and/or abnormal renal ultrasound results are usually seen in advanced CKD, so no diagnosis is required.
Patients with CKD can diagnose liver cirrhosis by histopathology or liver ultrasound, as well as clinical manifestations of portal hypertension and/or liver decompensation.
The most widely used biomarker for evaluating kidney damage in patients with liver cirrhosis is urinary neutrophil gelatinase-associated lipocalin (uNGAL), an inflammatory biomarker produced by damaged renal tubular cells.
uNGAL is positively correlated with the severity of renal dysfunction in CKD patients, indicating that it has prognostic significance for CKD.
However, the prognostic value of uNGAL in patients with liver cirrhosis and CKD is unclear.
Renal dual-function Doppler ultrasonography is a simple, non-invasive, and efficient method that can be applied to patients with liver cirrhosis to study intra-renal hemodynamics.
This is a test that evaluates renal vascular resistance as a marker of vasoconstriction.
The renal resistance index (RRI) can be used to detect early renal insufficiency in patients with liver cirrhosis.
Treatment of cirrhosis with CKD There are many challenges in the treatment of cirrhosis with CKD, especially in controlling the flow of ascites and edema.
There are several limitations to diuretic treatment.
Patients with functional CKD are usually not treated with diuretics because they may further aggravate renal failure by causing a decrease in the intravascular volume, and may induce electrolyte imbalance.
Diuretics seem to be used to treat ascites and edema in patients with structural CKD, but CKD patients usually have different degrees of diuretic resistance, so higher doses of diuretics are needed to overcome it.
Vasopressin 2 receptor antagonist Vaptan can be considered for the treatment of patients with liver cirrhosis and CKD who are intolerant or poorly responding to diuretics.
Most current guidelines do not recommend the use of vasoconstrictors in functional CKD.
Transjugular intrahepatic portosystemic shunt (TIPS) can reduce portal pressure, improve renal function and reduce ascites.
TIPS appears to be very effective in patients with functional CKD, and limited data indicate that it is also effective in structural CKD.
However, TIPS may increase the incidence of hepatic encephalopathy (HE), so patients with encephalopathy, cardiopulmonary disease, and severe liver dysfunction should avoid using TIPS.
As the evaluation of renal function in patients with advanced liver cirrhosis may be difficult, renal biopsy should be considered as much as possible to determine the changes in renal parenchyma, and to decide whether to perform LT or combined liver and kidney transplantation (SLKT).
Patients with low eGFR and renal biopsy showing glomerular sclerosis and/or interstitial fibrosis> 30% should be considered for SLKT.
Literature index: Kumar R, Priyadarshi RN, Anand U.
Chronic renal dysfunction in cirrhosis: A new frontier in hepatology[J].
World J Gastroenterol.
2021 Mar 21;27(11):990-1005.
Contribution email: tougao@medlive .
cn
However, in the past decade, the incidence of CKD in patients with liver cirrhosis has risen sharply.
The main reason for the increase in the prevalence of CKD seems to be the increasing awareness of this disease, as well as the increasing prevalence of diabetes (DM), hypertension, and non-alcoholic fatty liver disease (NAFLD).
This review provides a detailed overview of liver cirrhosis with CKD, including its clinical impact and the difficulties that clinicians may face in diagnosis and treatment.
The definition and classification of liver cirrhosis with CKD The current definition of liver cirrhosis with CKD is: the estimated glomerular filtration rate (eGFR) is reduced to <60 mL/min and more than 3 according to the modified kidney disease diet (MDRD)-6 formula month.
Currently, the diagnosis of CKD does not require conclusive evidence of kidney damage, such as proteinuria, hematuria, renal imaging or pathological abnormalities.
The organization to improve the prognosis of global kidney disease has divided CKD into structural and functional categories based on whether there is kidney damage.
Patients with liver cirrhosis may have some risk factors for structural CKD, such as DM, NAFLD and atherosclerosis.
In addition, the continuous renal vasoconstriction of functional CKD can lead to structural changes, turning it into structural CKD.
The clinical impact of cirrhosis with CKD CKD can affect the clinical manifestations, complications, treatment strategies and outcomes of patients with liver cirrhosis in many ways.
In patients with liver cirrhosis, CKD may cause ascites and edema in various ways, such as nephrogenic ascites, chronic fluid overload, hypoproteinemia and cardiomyopathy.
Due to a variety of complex hemostatic abnormalities, patients with liver and kidney dysfunction may have a higher bleeding tendency.
CKD is an independent risk factor for cardiovascular death and can aggravate anemia caused by cirrhosis.
Both CKD and liver cirrhosis can cause immunosuppression, leading to an increased risk of infection.
Patients with liver cirrhosis and CKD appear to have an increased risk of malignant tumors.
After adjusting for many possible confounding factors, the reduction in GFR has been shown to be independently associated with the increased risk of renal cell carcinoma and urothelial carcinoma.
CKD is associated with increased mortality of liver cancer, kidney cancer and urothelial cancer.
Since liver and kidney diseases can independently cause anorexia, anemia, ascites, bleeding tendency, and encephalopathy, it is often difficult to determine which disease causes the above symptoms in patients with cirrhosis and CKD.
This may make it difficult to determine the best treatment options (such as the need for renal replacement therapy).
Liver cirrhosis with CKD is associated with adverse outcomes and increased frequency of complications.
Wong et al.
found that compared with patients with cirrhosis without CKD, patients with cirrhosis and CKD had a higher incidence of acute kidney injury (AKI), the need for dialysis, and the 30-day mortality rate.
A study by Bassegoda et al.
showed that compared with patients without CKD, patients with liver cirrhosis and CKD have a higher risk of AKI, refractory ascites, bacterial infection, and liver transplantation (LT) requirements.
In addition, liver cirrhosis is independently associated with the adverse outcomes of CKD patients.
Diagnosis and evaluation of cirrhosis with CKD The diagnosis of cirrhosis with CKD is based on GFR (the expert panel recommends MDRD-6 to evaluate eGFR).
Abnormal urinalysis and/or abnormal renal ultrasound results are usually seen in advanced CKD, so no diagnosis is required.
Patients with CKD can diagnose liver cirrhosis by histopathology or liver ultrasound, as well as clinical manifestations of portal hypertension and/or liver decompensation.
The most widely used biomarker for evaluating kidney damage in patients with liver cirrhosis is urinary neutrophil gelatinase-associated lipocalin (uNGAL), an inflammatory biomarker produced by damaged renal tubular cells.
uNGAL is positively correlated with the severity of renal dysfunction in CKD patients, indicating that it has prognostic significance for CKD.
However, the prognostic value of uNGAL in patients with liver cirrhosis and CKD is unclear.
Renal dual-function Doppler ultrasonography is a simple, non-invasive, and efficient method that can be applied to patients with liver cirrhosis to study intra-renal hemodynamics.
This is a test that evaluates renal vascular resistance as a marker of vasoconstriction.
The renal resistance index (RRI) can be used to detect early renal insufficiency in patients with liver cirrhosis.
Treatment of cirrhosis with CKD There are many challenges in the treatment of cirrhosis with CKD, especially in controlling the flow of ascites and edema.
There are several limitations to diuretic treatment.
Patients with functional CKD are usually not treated with diuretics because they may further aggravate renal failure by causing a decrease in the intravascular volume, and may induce electrolyte imbalance.
Diuretics seem to be used to treat ascites and edema in patients with structural CKD, but CKD patients usually have different degrees of diuretic resistance, so higher doses of diuretics are needed to overcome it.
Vasopressin 2 receptor antagonist Vaptan can be considered for the treatment of patients with liver cirrhosis and CKD who are intolerant or poorly responding to diuretics.
Most current guidelines do not recommend the use of vasoconstrictors in functional CKD.
Transjugular intrahepatic portosystemic shunt (TIPS) can reduce portal pressure, improve renal function and reduce ascites.
TIPS appears to be very effective in patients with functional CKD, and limited data indicate that it is also effective in structural CKD.
However, TIPS may increase the incidence of hepatic encephalopathy (HE), so patients with encephalopathy, cardiopulmonary disease, and severe liver dysfunction should avoid using TIPS.
As the evaluation of renal function in patients with advanced liver cirrhosis may be difficult, renal biopsy should be considered as much as possible to determine the changes in renal parenchyma, and to decide whether to perform LT or combined liver and kidney transplantation (SLKT).
Patients with low eGFR and renal biopsy showing glomerular sclerosis and/or interstitial fibrosis> 30% should be considered for SLKT.
Literature index: Kumar R, Priyadarshi RN, Anand U.
Chronic renal dysfunction in cirrhosis: A new frontier in hepatology[J].
World J Gastroenterol.
2021 Mar 21;27(11):990-1005.
Contribution email: tougao@medlive .
cn
