Risk Factors and Outcome of 107 Patients with Decompensated Liver Disease and Acute Renal Failure (Including 26 Patients with Hepatorenal Syndrome): The Role of Hemodialysis

Abstract

The prognosis of acute renal failure in patients with preexisting liver decompensation is poor, and hemodialysis is considered futile, especially for hepatorenal syndrome (HRS). Since we observed a more favorable outcome in some patients, we retrospectively evaluated 107 patients with decompensated liver disease and acute renal failure (serum creatinine > 200 mumol/L) treated at the medical department of a university hospital in a 10-year period (1980-1990). HRS in the strict sense (urine-Na < 20 mmol/L while on furosemide) was diagnosed in 26 of 107 patients (24%). Renal function remained compensated in 25 patients, while 82 patients fulfilled the criteria for dialysis treatment (creatinine > 500 mumol/L and/or diuresis < 500 mL/day). In contrast to the current doctrine, 38 of the 82 patients were given hemodialysis (46%). Using the Cox proportional hazard model, the relative risk (presence vs. absence of a risk factor) of dying was increased 8.2-fold (3.9-17.2) in patients with thrombocytopenia < 100/nL, 3.9-fold (1.4-11.3) in those with hepatic encephalopathy and prothrombin time < 30%, 2.8-fold (1.6-4.8) in patients with malignoma, and 2.7-fold (1.5-4.8) in patients not submitted to dialysis despite its indication. In the CART statistics (classification and regression trees), the 33 patients with the poorest outcome were characterized exclusively by thrombocytopenia < 100/nL. HRS in the strict sense was not an independent risk factor. The CART group of 43 patients with favorable prognosis (compensated renal failure or treatment by hemodialysis, absent malignancy) had a 1-year survival rate of 38%. We conclude that thrombocytopenia, encephalopathy, and malignoma, but not HRS per se, are fatal signs that make hemodialysis futile in patients with acute renal failure and decompensated liver disease.

Cirrhosis and Renal Dysfunction

“…HRS tanılı 24 hastanın retrospektif olarak incelendiği bir çalışmada; karaciğer nakli sonrası sağ kalım RRT alanlarda %44, RRT almayanlarda %10 olarak bulunmuştur (33). Diğer bir çalışmada RRT alan ve almayan toplam 80 HRS tip 1 hastası analiz edildiğinde, her iki grup arasında kısa (30 gün) ve uzun dönem (180 gün) mortalite açısından fark görülmemiştir.…”

Drug therapies in liver disease

“…It is often advocated that it is important to rule out other forms of acute liver injury that might respond well to renal replacement and, although mortality remains high, there are intriguing suggestions that HRS per se is not associated with a worse outcome in patients on dialysis, 33 although published data remain scarce.…”

Hepatorenal syndrome

“…Survival on dialysis is generally dependent on the severity of liver disease [52] . There are only a few small studies evaluating the effects of dialysis in HRS [53,54] . Keller et al [54] , in a retrospective study, found that 7 of 16 patients with HRS who received RRT survived, while only 1 out of 16 patients with HRS who did not receive RRT survived.…”

“…There are only a few small studies evaluating the effects of dialysis in HRS [53,54] . Keller et al [54] , in a retrospective study, found that 7 of 16 patients with HRS who received RRT survived, while only 1 out of 16 patients with HRS who did not receive RRT survived. In the prospective study by Witzke et al [53] , 30 patients with Child-Pugh C cirrhosis and HRS were treated with continuous veno-venous hemodialysis (CVVHD) if they were on mechanical ventilation, or with intermittent hemodialysis if they were not on mechanical ventilation.…”