Akutes Nierenversagen infolge eines hepatorenalen Syndroms

ZUSAMMENFASSUNG

Das akute Nierenversagen (AKI: „acute kidney injury“) infolge eines hepatorenalen Syndroms (AKI-HRS) kommt nur bei Patienten mit Leberzirrhose und Aszites vor. AKI-HRS muss jedoch von anderen Ursachen des AKI abgegrenzt werden, die weitaus häufiger vorkommen. Zu nennen wären Volumenmangel, Infektionen, Gebrauch von tubulotoxischen Substanzen sowie Komorbiditäten einschließlich akuter Verschlechterungen vorbestehender chronischer Nierenerkrankungen anderer Genese, wie z. B. bei Diabetes, arterieller Hypertonie, Herzinsuffizienz und Glomerulonephritiden. Der aktuelle Expertenkonsensus hat die bisherigen Diagnosekriterien gelockert. Dennoch sollte die Diagnose eines AKI-HRS in klarer Abgrenzung zu einer vorbestehenden chronischen Nierenerkrankung oder hinsichtlich anderer Ursachen des AKI erfolgen. Dazu ist ein interdisziplinäres Management der Patienten unabdingbar. Volumenmanagement, Terlipressin und Albumin sind die führenden Säulen in der Therapie des AKI-HRS. Die Indikation zur Lebertransplantation sollte in allen Fällen geprüft werden und daher die schnelle Überweisung an spezialisierte Zentren nach sich ziehen, sofern die Patienten Transplantationskandidaten sein könnten. Die Notwendigkeit und Dauer einer Dialysetherapie müssen individuell geprüft werden.

Publication History

Article published online:
06 September 2024

• Literatur

• 1 Gu W, Hortlik H, Erasmus HP. et al Trends and the course of liver cirrhosis and its complications in Germany: nationwide population-based study (2005 to 2018). Lancet Reg Health Eur 2022; 12: 100240
• 2 de Franchis R, Bosch J, Garcia-Tsao G. et al Baveno VII – Renewing consensus in portal hypertension. J Hepatol 2022; 76: 959-974
• 3 D’Amico G, Pasta L, Morabito A. et al Competing risks and prognostic stages of cirrhosis: a 25-year inception cohort study of 494 patients. Aliment Pharmacol Ther 2014; 39: 1180-1193
• 4 D’Amico G, Zipprich A, Villanueva C. et al Further decompensation in cirrhosis: Results of a large multicenter cohort study supporting Baveno VII statements. Hepatology 2024; 79: 869-881
• 5 Wolf G, von Schrenck T. Das hepatorenale Syndrom: Pathophysiologie, Diagnostik und Therapie. Dtsch Arztebl. 2000 97. A-2858/B-2423/C-2158
• 6 Bernardi M, Moreau R, Angeli P. et al Mechanisms of decompensation and organ failure in cirrhosis: from peripheral arterial vasodilation to systemic inflammation hypothesis. J Hepatol 2015; 63: 1272-1284
• 7 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: 164-176
• 8 Gerbes AL, Labenz J, Appenrodt B. et al [Updated S2k-Guideline “Complications of liver cirrhosis”. German Society of Gastroenterology (DGVS)]. Z Gastroenterol 2019; 57: 611-680
• 9 Larrue H, D’Amico G, Olivas P. et al TIPS prevents further decompensation and improves survival in patients with cirrhosis and portal hypertension in an individual patient data meta-analysis. J Hepatol 2023; 79: 692-703
• 10 Bureau C, Thabut D, Oberti F. et al Transjugular intrahepatic portosystemic shunts with covered stents increase transplant-free survival of patients with cirrhosis and recurrent ascites. Gastroenterology 2017; 152: 157-163
• 11 Stadlbauer V, Wright GA, Banaji M. et al Relationship between activation of the sympathetic nervous system and renal blood flow autoregulation in cirrhosis. Gastroenterology 2008; 134: 111-119
• 12 Izzy M, VanWagner LB, Lin G. et al Redefining cirrhotic cardiomyopathy for the modern era. Hepatology 2020; 71: 334-345
• 13 Nadim MK, Garcia-Tsao G. Acute kidney injury in patients with cirrhosis. N Engl J Med 2023; 388: 733-745
• 14 Nazal L, Cárdenas A. Prognostic markers in patients with ascites and hepatorenal syndrome. Dis Markers 2011; 31: 139-146
• 15 Belcher JM, Garcia-Tsao G, Sanyal AJ. et al Association of AKI with mortality and complications in hospitalized patients with cirrhosis. Hepatology 2013; 57: 753-762
• 16 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. J Hepatol 2015; 62: 968-974
• 17 Martín-Llahí M, Guevara M, Torre A. et al Prognostic importance of the cause of renal failure in patients with cirrhosis. Gastroenterology 2011; 140: 488-496.e4
• 18 Patidar KR, Belcher JM, Regner KR. et al Incidence and outcomes of acute kidney injury including hepatorenal syndrome in hospitalized patients with cirrhosis in the US. J Hepatol 2023; 79: 1408-1417
• 19 KDIGO KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int 2012; 02 (Suppl. 01) 1-138
• 20 Nadim MK, Kellum JA, Davenport A. et al Hepatorenal syndrome: the 8th International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2012; 16: R23
• 21 Wong F, Nadim MK, Kellum JA. et al Working Party proposal for a revised classification system of renal dysfunction in patients with cirrhosis. Gut 2011; 60: 702-709
• 22 Amathieu R, Al-Khafaji A, Sileanu FE. et al Significance of oliguria in critically ill patients with chronic liver disease. Hepatology 2017; 66: 1592-1600
• 23 Nadim MK, Kellum JA, Forni L. et al Acute kidney injury in patients with Cirrhosis: Acute disease quality Initiative (ADQI) and International Club of Ascites (ICA) joint multidisciplinary consensus meeting. J Hepatol 2024; 81: 163-183
• 24 Moreau R, Jalan R, Gines P. et al Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013; 144 1426–1437 1437.e1-9
• 25 Maiwall R, Sarin SK, Moreau R. Acute kidney injury in acute on chronic liver failure. Hepatol Int 2016; 10: 245-257
• 26 Pouria S, Feehally J. Glomerular IgA deposition in liver disease. Nephrol Dial Transplant 1999; 14: 2279-2282
• 27 Cavallin M, Piano S, Romano A. et al Terlipressin given by continuous intravenous infusion versus intravenous boluses in the treatment of hepatorenal syndrome: a randomized controlled study. Hepatology 2016; 63: 983-992
• 28 Wong F, Pappas SC, Reddy KR. et al Terlipressin use and respiratory failure in patients with hepatorenal syndrome type 1 and severe acute-on-chronic liver failure. Aliment Pharmacol Ther 2022; 56: 1284-1293
• 29 Ortega R, Gines P, Uriz J. et al Terlipressin therapy with and without albumin for patients with hepatorenal syndrome: results of a prospective, nonrandomized study. Hepatology 2002; 36: 941-948
• 30 Israelsen M, Krag A, Allegretti AS. et al Terlipressin versus other vasoactive drugs for hepatorenal syndrome. Cochrane Database Syst Rev 2017; 09: CD011532
• 31 Arora V, Maiwall R, Rajan V. et al Terlipressin is superior to noradrenaline in the management of acute kidney injury in acute on chronic liver failure. Hepatology 2020; 71: 600-610
• 32 Martín-Llahí 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: 1352-1359
• 33 Wong F, Pappas SC, Curry MP. et al Terlipressin plus albumin for the treatment of type 1 hepatorenal syndrome. N Engl J Med 2021; 384: 818-828
• 34 Boyer TD, Sanyal AJ, Wong F. et al Terlipressin plus albumin is more effective than albumin alone in improving renal function in patients with cirrhosis and hepatorenal syndrome type 1. Gastroenterology 2016; 150: 1579-1589.e2
• 35 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: 1360-1368
• 36 Piano S, Schmidt HH, Ariza X. et al Association between grade of acute on chronic liver failure and response to terlipressin and albumin in patients with hepatorenal syndrome. Clin Gastroenterol Hepatol 2018; 16: 1792-1800.e3
• 37 Boyer TD, Sanyal AJ, Garcia-Tsao G. et al Predictors of response to terlipressin plus albumin in hepatorenal syndrome (HRS) type 1: relationship of serum creatinine to hemodynamics. J Hepatol 2011; 55: 315-321
• 38 Belcher JM. Is there a role for dialysis in patients with hepatorenal syndrome who are not liver transplant candidates?. Semin Dial 2014; 27: 288-291
• 39 Allegretti AS, Parada XV, Eneanya ND. et al Prognosis of patients with cirrhosis and AKI who initiate RRT. Clin J Am Soc Nephrol 2018; 13: 16-25
• 40 Bundesärztekammer Richtlinie gem. § 16 Abs. 1 S. 1 Nrn. 2 u. 5 TPG für die Wartelistenführung und die Organvermittlung zur Nierentransplantation. Dtsch Arztebl 2023; 120: A116
• 41 Ripoll C, Platzer S, Franken P. et al Liver-HERO: hepatorenal syndrome-acute kidney injury (HRS-AKI) treatment with transjugular intrahepatic portosystemic shunt in patients with cirrhosis – a randomized controlled trial. Trials 2023; 24: 258
• 42 European Association for the Study of the Liver. Electronic address eee, European Association for the Study of the L EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69: 406-460