Renal failure in liver disease.

Progressive renal failure in cirrhosis and fulminant liver disease remains an adverse prognostic factor. Irrespective of the type of renal functional impairment which ranges form "prerenal failure" to "hepatorenal syndrome" and "acute tubular necrosis", renal hypoperfusion, as a consequence of either reduced perfusion pressure or increased renal vascular resistance, is an important pathomechanism. Awareness of the risk of renal failure and avoidance of nephrotoxic agents and of brisk reductions in effective circulating volume are important for prevention. Plasma volume expansion, on the other hand, is mandatory in trying to reverse incipient renal functional impairment. Pharmacological attempts to improve renal hemodynamics by lowering renal and increasing extrarenal vascular resistance have so far largely been disappointing. However, increasing knowledge about mediators and synthesis of specific agonists and antagonists, such as those against endothelin or antidiuretic hormone, may add promising treatment options in the near future. TIPS is another therapeutic tool of potential interest in the management of renal failure in liver disease which needs further evaluation. Renal replacement therapy, preferentially in the form of continuous procedures, may be life-saving in those patients awaiting liver transplantation or spontaneous recovery of their hepatic function.