Renal replacement therapy in patients with chronic liver disease.

As the prevalence of chronic liver disease and chronic kidney disease (CKD) increase, clinicians are likely to be increasingly faced with difficult diagnostic, treatment, and ethical challenges when facing both of these diseases in a single patient. Alterations in creatinine formation and elimination in cirrhotic patients render creatinine-based estimates of glomerular filtration rate and dialysis adequacy less accurate in this population. Furthermore, differentiating signs and symptoms of uremia from hepatic disease may be difficult and clear indications for renal replacement therapy (RRT) in these patients have not been defined. Hemodialysis is associated with a high rate of complications and has not been shown to prolong life in cirrhotic patients with acute renal failure (ARF), but has not been carefully examined in those with CKD. Peritoneal dialysis is, similarly, unhelpful in chronic liver disease complicated by ARF, but has been found to be a viable option in some cirrhotic patients with CKD. Continuous RRT is generally tolerated by patients with decompensated cirrhosis and either acute or chronic renal failure and may act to bridge patients to liver transplantation. Given the poor underlying survival of cirrhotic patients with renal failure, clinicians should carefully consider the utility of RRT in each patient.