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Renal and hepatic functions are interrelated. Acute and chronic advanced liver disease is often complicated by renal dysfunction that typically worsens with prolonged time on the waiting list for liver transplantation.
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RENAL DYSFUNCTION ASSOCIATED WITH ACUTE LIVER FAILURE
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Renal failure is common in patients with acute liver failure (ALF). The etiology of this process relates to circulatory disturbances similar to those causing hepatorenal syndrome (HRS) in cirrhosis (reduced systemic vascular resistance with high cardiac output and renal vasoconstriction). On the other hand, the lack of significant portal hypertension in most patients with ALF and a prominent systemic inflammatory response syndrome make this process more similar to renal failure secondary to sepsis than to HRS associated with cirrhosis.
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Other factors contributing to renal failure in ALF include hypovolemia, administration of nephrotoxic drugs, infection, and disseminated intravascular coagulation (Figs. 102-1 and 102-2).
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In patients with ALF due to acetaminophen toxicity, the renal failure is often associated with concurrent direct nephrotoxicity leading to acute tubular necrosis (Fig. 102-3).
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RENAL DYSFUNCTION ASSOCIATED WITH CHRONIC LIVER FAILURE/CIRRHOSIS
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HRS, which is potentially reversible, is caused by portal hypertension leading to systemic and splanchnic arterial vasodilatation with hyperdynamic circulation and secondary renal vasoconstriction. HRS is characterized by the absence of significant structural changes in the renal parenchyma despite severe renal dysfunction and markedly decreased glomerular filtration rate (GFR). The diagnosis of HRS is based on well-defined criteria and requires exclusion of other causes of renal failure such as ...