Management der akuten Nierenschädigung bei Patienten mit akut-auf-chronischem Leberversagen

Renal function impairment is common in patients with decompensated cirrhosis. In the context of acute-on-chronic liver failure (ACLF), renal function impairment is almost always present. Nevertheless, there are relevant differences in the classification of renal function impairment in ACLF and its pathophysiology compared to decompensated cirrhosis. Indeed, in ACLF fixed cut-offs are used to define renal dysfunction (serum creatinine 1.5–1.9 mg/dl) and renal failure (serum creatinine > 2.0 mg/dl), whereas in decompensated cirrhosis relative changes are used to define the presence of acute kidney injury. Furthermore, in ACLF structural renal failure due to systemic inflammation and liver dysfunction is more common than in decompensated cirrhosis, where functional renal failure (due to hypovolemia or hepatorenal syndrome) is more frequent. Management of renal failure in ACLF is initially similar to that of decompensated cirrhosis. Due to intrinsic characteristics of ACLF, patients more often require circulatory support and therefore use of catecholamines. Renal replacement therapy should be considered on a case-by-case basis depending on the therapeutic options of the patients including liver transplantation. Liver support systems have not yet been shown to be of any benefit; however, clinical trials with newly designed systems which specifically address the pathophysiological changes which take place in ACLF are awaited.