Transplantation The definitive treatment for<unk>  is liver transplantation, and all other therapies can best be described as bridges to transplantation. While liver transplantation is by far the best available management option for<unk> , the mortality of individuals with<unk>  has been shown to be as high as 25% within the first month after transplantation. Individuals with<unk>  and evidence of greater hepatic dysfunction (quantified as MELD scores above 36) have been found to be at greatest risk of early mortality after liver transplantation. A further deterioration of kidney function even after liver transplantation in individuals with<unk>  has been demonstrated in several studies; however, this is transient and thought to be due to the use of medications with toxicity to the kidneys, and specifically the introduction of immunosuppressants such as tacrolimus and cyclosporine that are known to worsen kidney function. Over the long-term, however, individuals with<unk>  who are the recipients of liver transplants almost universally recover kidney function, and studies show that their survival rates at three years are similar to those who have received liver transplants for reasons other than<unk> . In anticipation of liver transplantation (which may be associated with considerable in-hospital delay), several other strategies have been found to be beneficial in preserving kidney function. These include the use of intravenous albumin infusion, medications (for which the best evidence is for analogues of vasopressin, which causes splanchnic vasoconstriction), radiological shunts to decrease pressure in the portal vein, dialysis, and a specialized albumin-bound membrane dialysis system termed molecular adsorbents recirculation system (MARS) or liver dialysis. Medical therapy Many major studies showing improvement in kidney function in patients with<unk>  have involved expansion of the volume of the plasma with albumin given intravenously. The quantity of albumin administered intravenously varies: one cited regimen is 1 gram of albumin per kilogram of body weight intravenously on the first day, followed by 20 to 40 grams daily. Notably, studies have shown that treatment with albumin alone is inferior to treatment with other medications in conjunction with albumin; most studies evaluating pre-transplant therapies for<unk>  involve the use of albumin in conjunction with other medical or procedural treatment. Midodrine is an alpha-agonist and octreotide is an analogue of somatostatin, a hormone involved in regulation of blood vessel tone in the gastrointestinal tract. The medications are respectively systemic vasoconstrictors and inhibitors of splanchnic vasodilation, and were not found to be useful when used individually in treatment of<unk> . However, one study of 13 patients with<unk>  showed significant improvement in kidney function when the two were used together (with midodrine given orally, octreotide given subcutaneously and both dosed according to blood pressure), with three patients surviving to discharge. Another nonrandomized, observational study of individuals with<unk>  treated with subcutaneous octreotide and oral midodrine showed that there was increased survival at 30 days. The vasopressin analogue ornipressin was found in a number of studies to be useful in improvement of kidney function in patients with<unk> , but has been limited in its use, as it can cause severe ischemia to major organs. Terlipressin is a vasopressin analogue that has been found in one large study to be useful for improving kidney function in patients with<unk>  with a lesser incidence of ischemia but is not available in the United States. A randomized control trial led by Florence Wong demonstrated improved renal function in individuals with Type 1<unk>  treated with terlipressin and albumin over placebo. A key criticism of all of these medical therapies has been heterogeneity in the populations investigated and the use of kidney function, instead of mortality, as an outcome measure. Other agents that have been investigated for use in treatment of<unk>  include pentoxifylline, acetylcysteine, and misoprostol. The evidence for all of these therapies is based on either case series, or in the case of pentoxifylline, extrapolated from a subset of patients treated for alcoholic hepatitis. Procedural treatments TIPS, shown in progress here, has been shown to improve kidney function in individuals with<unk>  if portal pressures decrease after the procedure. A transjugular intrahepatic portosystemic shunt (TIPS) involves the decompression of the high pressures in the portal circulation by placing a small stent between a portal and hepatic vein. This is done through radiologically guided catheters which are passed into the hepatic vein either through the internal jugular vein or the femoral vein. Theoretically, a decrease in portal pressures is thought to reverse the hemodynamic phenomena that ultimately lead to the development of<unk> . TIPS has been shown to improve kidney function in patients with<unk> . Complications of TIPS for treatment of<unk>  include the worsening of hepatic encephalopathy (as the procedure involves the forced creation of a porto-systemic shunt, effectively bypassing the ability of the liver to clear toxins), inability to achieve adequate reduction in portal pressure, and bleeding. Liver dialysis involves extracorporeal dialysis to remove toxins from the circulation, usually through the addition of a second dialysis circuit that contains an albumin-bound membrane. The molecular adsorbents recirculation system (MARS) has shown some utility as a bridge to transplantation in patients with<unk> , yet the technique is still nascent. Renal replacement therapy may be required to bridge individuals with<unk>  to liver transplantation, although the condition of the patient may dictate the modality used. The use of dialysis, however, does not lead to recuperation or preservation of kidney function in patients with<unk> , and is essentially only used to avoid complications of kidney failure until transplantation can take place. In patients who undergo hemodialysis, there may even be an increased risk of mortality due to low blood pressure in patients with<unk> , although appropriate studies have yet to be performed. As a result, the role of renal replacement therapy in patients with<unk>  remains unclear.
Hepatorenal syndrome
Conorenal syndrome
Papillorenal syndrome
Nephritic syndrome
Cardiorenal syndrome
Hemolytic–uremic syndrome
Dialysis disequilibrium syndrome
Acute uric acid nephropathy