Renal and circulatory dysfunction in liver cirrhosis. Pathogenesis and treatment

Abstract

SUMMARY
The clinical course of patients with cirrhosis is complicated
by several disorders independent of the cause of the underlying
liver disease. These include portal hypertension
with development of esophageal varices, ascites and spontaneous
bacterial peritonitis, hepatorenal syndrome (HRS)
and hepatocellular carcinoma. Among these complications
the development of renal dysfunction and hepatorenal syndrome
are associated with a very poor prognosis. During
the course of cirrhosis a derangement in renal function leads
to an inability to maintain the extracellular fluid volume of
the body within normal limits. This abnormal extracellular
fluid volume regulation is associated with alterations
in the splanchnic and systemic circulation as well as functional
renal abnormalities that favor sodium and water retention.
For the most part, the predominant renal function
abnormality is sodium retention and its main clinical consequence
is the recurrent accumulation of extracellular fluid
as ascites and edema. In late stage cirrhosis, as renal function
becomes more impaired, the kidney is unable to handle
water properly and in addition the renal vasculature
becomes severely vasoconstricted. The main clinical consequences
of these two latter abnormalities are dilutional
hyponatremia and hepatorenal syndrome (HRS), respectively.
HRS is therefore a functional renal failure. In fact,
renal function returns to normal after patients with HRS
receive a liver transplantation. However, it should noted
that some patients with cirrhosis due to hepatitis B or C are at risk of developing organic renal failure secondary to
cryoglobulinemia or glomerulonephritis and these conditions
should be excluded prior to making the diagnosis of
HRS.