肝硬化患者容易发生急性肾损伤（acute kidney injury，AKI），可显著增加死亡率以及慢性肾脏病的风险。 肝肾综合征(hepatorenal syndrome，HRS)是AKI的一种特殊形式，具有特别高的死亡风险，早期识别HRS-AKI对于对症治疗逆转AKI至关重要。 国际腹水俱乐部（International Club of Ascites，ICA）和急性疾病质量倡议（Acute Disease Quality Initiative，ADQI）召开了一次联席会议，制定了HRS-AKI新的诊疗标准及建议，医脉通特将其摘译，以供临床医生参考。
01
Definition of acute kidney injury in cirrhosis
肝硬化AKI采用肾病疾病改善全球指南（Kidney Disease: Improving Global Outcomes，KDIGO）标准定义，即：
Serum creatinine elevated ≥0.3 mg/dL (26.5 micromol/L) over 48 hours and/or urine output lasting more than 6 hours ≤0.5 ml/kg.
The diagnostic criteria for HRS-AKI are:
a) cirrhosis with ascites;
b) an increase in serum creatinine ≥0.3 mg/dl (26.5 micromol/L) over 48 hours and/or a urine output lasting more than 6 hours ≤0.5 ml/kg);
c) No improvement in serum creatinine and/or urine output within 24 hours of adequate volume resuscitation.
02
Prevention of acute kidney injury in cirrhosis
Prevention strategies for AKI include individualized assessment of kidney-liver health (KLH), nephrotoxin management, and liver-specific recommendations for expected and unintended exposures.
建议使用20-25%白蛋白来预防腹腔穿刺术(large volume paracentesis，LVP)后和自发性细菌性腹膜炎(spontaneous bacterial peritonitis，SBP)患者发生AKI（强烈推荐，B级）。 白蛋白给药的剂量和持续时间应根据患者的血流动力学和容量状态调整。
Systemic use of albumin in patients with decompensated cirrhosis is not recommended to prevent AKI in non-SBP-infected patients and to maintain a serum albumin concentration of > 3.0 g/dl (highly recommended, grade A).
03
Treatment of acute kidney injury in cirrhosis
It is recommended to recommend individualized AKI management strategies based on the patient's individual renal and hepatic health status and AKI phenotype.
A combination of physical examination, imaging studies, and static and dynamic measurements is recommended to guide the patient's fluid management, and is assessed at all stages of treatment to avoid volume overload.
Crystalloid (preferably equilibrium solution) is recommended as first-line treatment for patients with AKI who require fluid resuscitation, unless there is a specific indication for the use of other fluids (highly recommended, grade B).
Patients with AKI who present with signs or symptoms of volume overload are advised to discontinue all fluid therapy and start diuretic therapy or renal replacement therapy (RRT). The timing of RRT in patients with cirrhosis should be individualized, taking into account the trajectory of kidney and liver health, and treated as early as possible before significant complications develop.
A rapid evaluation for transplantation is recommended for patients with decompensated cirrhosis after an attack of AKI.
Bibliography:
Nadim MK, Kellum JA, Forni L, Francoz C, Asrani SK, Ostermann M, Allegretti AS, Neyra JA, Olson JC, Piano S, VanWagner LB, Verna EC, Akcan-Arikan A, Angeli P, Belcher JM, Biggins SW, Deep A, Garcia-Tsao G, Genyk YS, Gines P, Kamath PS, Kane-Gill SL, Kaushik M, Lumlertgul N, Macedo E, Maiwall R, Marciano S, Pichler RH, Ronco C, Tandon P, Velez JQ, Mehta RL, Durand F. 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 Mar 26:S0168-8278(24)00214-9.
Source: Yimaitong Hepatology