Insuffisance rénale aiguë chez les patients cirrhotiques en réanimation : incidence et pronostic

Patients with advanced or decompensated cirrhosis frequently develop disturbed renal function, including sodium and water retention, and renal failure. Acute renal failure (ARF) is a serious complication and constitutes a major source of mortality. The main causes of ARF are prerenal failure, including type 1 hepatorenal syndrome (HRS) and acute tubular necrosis, in a context of sepsis, upper gastrointestinal bleeding, hypovolemia, or toxic insult. Prerenal failure due to true hypovolemia is rapidly reversible after fluid loading. By contrast, type 1 HRS is not reversible after volume expansion and is associated with a very poor short-term prognosis in absence of liver transplantation. Some therapeutics such as the combination of vasopressor and albumin, TIPS or MARS® (molecular adsorbents recirculating system) may improve the renal function in waiting patients for liver transplantation. Acute tubular necrosis is mainly due to renal tubular ischemia induced by severe and sustained prerenal failure. In these severe conditions of multiorgan failure syndrome, the use of renal replacement therapy remains to be questioned, since most of patients with acute on chronic liver cirrhosis associated with organ dysfunction are likely to die before discharge from the hospital.