Renal failure after upper gastrointestinal bleeding in cirrhosis: Incidence, clinical course, predictive factors, and short-term prognosis

Abstract

Patients with advanced cirrhosis commonly develop disturbances in renal function, such as sodium retention, water retention, and renal failure. 1-4 Among them, renal failure is the most relevant in clinical practice, because its appearance usually entails a very poor prognosis. 1-4 Several factors predisposing to the development of renal failure in patients with cirrhosis have been identified, including spontaneous bacterial peritonitis, large-volume paracentesis without intravenous administration of albumin, and treatment with several drugs, such as nonsteroidal anti-inflammatory drugs or aminoglycosides. [3][4][5] Despite the high frequency and clinical importance of gastrointestinal bleeding in cirrhosis, no studies have so far been reported aimed at specifically assessing the relationship between bleeding and renal failure in patients with cirrhosis. Several factors related with gastrointestinal bleeding may have a deleterious effect on kidney function. First, the reduced intravascular volume caused by the blood loss may cause renal hypoperfusion and lead to a reduction in glomerular filtration rate. Second, renal function may also be adversely affected by bacterial infections, which develop frequently in the setting of gastrointestinal bleeding. 5,6 Finally, it has been proposed that small losses of blood volume not sufficient by themselves to cause a reduction in renal perfusion in patients without liver disease would aggravate the already-reduced effective arterial blood volume present in advanced cirrhosis and trigger the development of hepatorenal syndrome. 7 The current study was undertaken to assess the incidence, clinical course, predictive factors, and short-term prognosis of renal failure after gastrointestinal bleeding in a large series of consecutive patients with cirrhosis seen in a specialized gastrointestinal unit of a tertiary referral center. Moreover, to investigate whether cirrhosis per se is a predisposing factor for the development of renal failure after gastrointestinal bleeding, the incidence of renal failure in patients with cirrhosis was compared with that of a group of noncirrhotic patients matched by age and intensity of the bleeding episode. PATIENTS AND METHODS Study PopulationThe clinical records of 192 consecutive episodes of upper-gastrointestinal bleeding in 178 patients with cirrhosis admitted to the liver unit of Hospital Clínic of Barcelona during a 2-year period were reviewed. Patients with a hospital stay or survival of less than 48 hours after bleeding (8 and 9 patients, respectively) were excluded from the analysis. Therefore, the study was performed in a total of 175 episodes of upper-gastrointestinal bleeding in 161 patients. Of them, 104 patients were receiving diuretics before admisssion, and 21 patients were receiving ␤-blockers (10 of these latter patients were treated with a combination of ␤-blockers and nitrates).Abbreviations: PRBC, packed red blood cell; ATN, acute tubular necrosis.

Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis

“…The most important of these are infection, bleeding and large-volume paracentesis without albumin administration. [29][30][31][32] The role of SBP has recently been emphasised. Table 1 compares the results of two studies 29 30 assessing the prevalence of renal failure in cirrhotic patients with SBP and in those with infections unrelated to SBP, and shows that: (a) in spite of an effective antibiotic therapy, a significant proportion of cirrhotic patients with bacterial infection develop progressive renal failure.…”

Acute kidney injury is independently associated with death in patients with cirrhosis

“…There has also been a lack of standardisation in defining these thresholds. [10][11][12][13] A more evolved approach to defining acute renal dysfunction has come with the widespread acceptance of consensus criteria for acute kidney injury (AKI) that provide a method of diagnosing and describing the severity of renal dysfunction based on individualised changes in serum creatine and urine output. The Kidney Disease: Improving Global Outcomes (KDIGO) diagnostic criteria are the most current, 14 combining the earlier acute kidney injury network (AKIN) 15 and Risk of renal dysfunction; Injury to the kidney; Failure of kidney function; Loss of kidney function; and End-stage kidney disease (RIFLE) classifications.…”

Nonendoscopic Management Strategies for Acute Esophagogastric Variceal Bleeding

“…Of note, most deaths are unrelated to bleeding per se and are rather caused by complications of bleeding such as liver failure, infections and hepatorenal syndrome 21,22 . The degree of liver dysfunction, creatinine level, hypovolemic shock, active bleeding on endoscopy, and presence of hepatocellular carcinoma are important determinants of adverse outcome 21,22,23,24,25 . Thus, the management of patients with acute variceal bleeding includes not only treatment and control of active bleeding but also the prevention of rebleeding, hepatic encephalopathy, infections and renal failure 26 .…”

“…Acute renal failure in a patient with cirrhosis is a severe complication and often a harbinger of death 43 , while serum creatinine is a key component of the model for end-stage liver disease (MELD) score, a well-established predictor of mortality 44 . Renal failure in a patient with acute variceal bleeding is also a predictor of increased mortality, hence physicians should not just focus on the bleeding alone, but measures should be taken to prevent the occurrence of renal failure 45 .…”