What should I do if patients with liver cirrhosis and ascites need renal replacement therapy?

Clinically, it is common in patients with liver cirrhosis and ascites because their own metabolic capacity is reduced, which leads to the accumulation of toxins, which makes the patient’s kidneys affected
.

Generally speaking, patients need renal replacement therapy (RRT) to clean up toxins in the blood, reduce fluid burden, etc.
, prolong the survival time of the patient and benefit the patient
.

 On June 5, 2021, the 58th Annual European Nephrology Conference (2021EDTA) was held in Berlin, Germany.
Experts from Spain and the United Kingdom discussed various aspects of RRT in patients with liver cirrhosis and ascites, including the pathological basis.
evaluation of a patient, the choice of renal replacement therapy, clinical routes
.

 The pathological basis of 2021EDTA liver cirrhosis can generally be divided into early stage (compensated stage), intermediate stage (decompensated stage) and late stage (further decompensated stage).
Their clinical manifestations and hepatic venous pressure gradient (HVPG) are as follows (Table 1 )
.

In general, as the liver condition deteriorates, it will affect various organs, including but not limited to the brain, lungs, cardiovascular system, and kidneys
.

For the kidneys, the main effects of liver cirrhosis include the accumulation of blood toxins, insufficient renal perfusion, and water and sodium retention.
In general, they are hepatorenal syndrome and ascites
.

Both hepatorenal syndrome and ascites are diseases with a high mortality rate.
Studies have shown that the 90-day mortality rate of patients with hepatorenal syndrome is 88.
33%
.

For patients with liver cirrhosis and ascites, whether to carry out RRT is a very important decision for clinical pathways
.

If the patient has a suitable liver source, if there is one, RRT can be started immediately until the liver transplantation is successful
.

It is worth noting that compared with other patients without cirrhosis, the survival rate of patients with cirrhosis receiving RRT is lower
.

Therefore, if the patient does not have a suitable liver source, it must be properly evaluated before starting RRT.
If the life expectancy is too short and the disease is irreversible, hospice care may be more important
.

 The specific clinical path diagram is as follows (Figure 1)
.

Different RRT choices Generally speaking, there are two common methods of RRT, namely peritoneal dialysis and hemodialysis.
So which dialysis method is more suitable for patients with liver cirrhosis and ascites? Spanish experts will analyze the advantages and disadvantages of peritoneal and hemodialysis Listed in the following table (Table 2)
.

Scholars systematically reviewed the clinical trials from 1977 to 2017, and found that after a total of 2136 patients, the survival rate of peritoneal dialysis patients was higher
.

Experts believe that this situation is closely related to the advantages of peritoneal dialysis
.

In addition, if the patient uses hemodialysis, more frequent dialysis can improve the survival rate of the patient
.

Evaluation and management of peritoneal dialysis patients 01 Evaluation experts suggest that the status assessment of peritoneal dialysis patients should not be single-factor evaluation, and multi-factor evaluation is required.
Specific indicators for evaluation include biomarkers, lung ultrasound, bioimpedance analysis, and blood volume monitoring, etc.
and so on
.

The specific situation is shown in the following table (Table 3)
.

02 Management experts believe that ascites management is very important for peritoneal dialysis patients
.

Ascites management is mainly divided into three major managements, namely overall management, drainage management, and drainage management of catheter packing
.

 ➤Overall management recommends that patients reduce supine time and reduce glucose intake; ➤Drainage management recommends that the drainage volume is allowed to exceed about 20% of the perfusion volume, and the perfusion volume can be gradually increased to 2-2.
5 liters, and each exchange can allow additional ultrafiltration 400-600ml ➤Drainage management at the catheter tamponade recommends that after 1 liter of ascites is drained, 1 liter of peritoneal dialysate should be injected, and then 1.
5 liters of peritoneal dialysate should be injected
.

 Generally speaking, doctors can judge whether a patient is overloaded by the following methods, including whether the patient has a change in mental state, increased hepatic and neck reflux, weight gain, and increased jugular venous pressure
.

Experts suggest that although changes in body weight and blood pressure are relatively easy to detect for peritoneal dialysis patients, the fluid balance of peritoneal dialysis patients is still challenging, and clinicians need to pay great attention to this
.

  Summary Experts conclude as follows: ➤Patients with liver disease will be prone to chronic kidney disease as the disease progresses; ➤Currently, the diagnosis and treatment of chronic kidney disease caused by liver disease are not fully developed; ➤whether RRT treatment for patients with advanced liver disease The development depends on the liver source and the patient's own wishes; ➤Peritoneal dialysis is a very good RRT treatment for advanced patients, which can increase the survival rate of patients; ➤Blood volume monitoring may be difficult to implement in some medical institutions, but it is very necessary ➤There is currently no large-scale clinical trial of RRT treatment for patients with liver cirrhosis and ascites, so more research is needed to establish the best plan
.

References 1.
Jose Jesus Broseta.
Choice of dialysis mode and adapting prescriptions of PDand HD for patients with cirrhosis and ascites.
ERA-EDTACongress Virtual meeting.
2021 June 05.