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Chronic Kidney Disease in Patients with Liver Cirrhosis: Current concepts, Controversies and Challenges
Ramesh Kumar1, Utpal Anand2, Rajeev Nayan Priyadarshi3
1Department of Gastroenterology, All India Institute of Medical Sciences, Patna, India. 2Department of surgical gastroenterology, All India Institute of Medical Sciences, Patna, India. 3Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna, India.

Corresponding Author
Dr Ramesh Kumar


The current definition of Chronic kidney disease (CKD) in patients with liver cirrhosis is based on decline in glomerular filtration rate (GFR)<60ml/min per 1.73m2 for 3 months. It includes both the organic-CKD due to structural damage to kidney; and functional-CKD due to circulatory and neurohormonal imbalances in cirrhosis. Emerging data suggest that incidence of CKD has considerably increased in cirrhotic patients over last decade. The available data on this condition is extremely limited. Many issues related to diagnosis and management of CKD in cirrhosis lack clarity which pose several challenges to the treating clinicians. The assessment of renal dysfunction and its chronicity is difficult in cirrhotic patients due to variable overestimation of GFR measured by creatinine-based formula, absence of reliable biomarkers of CKD and difficulty in performing renal biopsy in advanced cirrhotic patients. With both liver and kidney being dysfunctional, fluid mobilization to control ascites and edema becomes problematic. The diuretic resistance or contraindication are common, requirement of therapeutic paracentesis is often very high, transjugular intrahepatic portosystemic shunt is associated with very high risk of hepatic encephalopathy and hemodialysis is poorly tolerated in such patients. Moreover, prescribing medicines in patients with concomitant hepatorenal dysfunction is a challenging task. It is difficult to predict the reversibility of functional-CKD following liver transplantation, which complicates the decision regarding the need of simultaneous liver and kidney transplantation. This article provides a comprehensive review of current concepts, controversies and challenges with regard to the diagnosis, clinical evaluation and management of such patients.