Unpredictability of clinical evaluation of renal function in cirrhosis: Prospective study

doi:10.1016/0002-9343(87)90156-2

The American Journal of Medicine

Volume 82, Issue 5, May 1987, Pages 945-952

https://doi.org/10.1016/0002-9343(87)90156-2 Get rights and content

Abstract

The natural course of renal function in patients with cirrhosis and ascites but without azotemia is unclear. Therefore, a prospective evaluation of 23 non-azotemic cirrhotic patients with ascites was carried out over a three-year interval. Assessment included evaluation of serum electrolyte values, liver function tests, plasma renin levels, and parathyroid hormone levels. Renal function was determined by measurement of clearances of water and solute excretion, and simultaneous clearances of para-amino hippurate, inulin, and creatinine. The initial mean glomerular filtration rate was 66 mi/minute, serum creatinine level was 1.1 mg/dl, and blood urea nitrogen value was 13 mg/dl. The glomerular filtration rate showed marked variability among patients. On the basis of initial glomerular filtration rate, the patients were divided into three groups. Group I consisted of patients with supranormal filtration rates (mean 183 ml/minute), Group II constituted patients with normal filtration rates (mean 92 ml/minute), and Group III comprised patients with severely impaired filtration rates (mean 32 mi/minute). The serum creatinine level was below 1.5 mg/dl in all three groups. Serial measurement of renal function was performed in 18 patients over a mean of 310 days (range four to 1,176 days). Eighty-six percent of patients studied from Groups I and II maintained a normal or supranormal glomerular filtration rate over one year. However, most patients in Group III showed a progressive decline in filtration rate, despite no change in serum creatinine value. Sixty-seven percent of Group III patients died over a mean of one year. The mean 24-hour solute excretion among Group III patients was only 263 mOsm per day, significantly less than the control value of 874 mOsm per day in other hospitalized non-cirrhotic patients. The serum creatinine level frequently failed to rise above normal even when the glomerular filtration rate was very low (less than 25 ml/minute), and creatinine clearance overestimated inulin clearance by a factor of two in Group III patients. However, the creatinine index was an aid in determining true glomerular filtration rate and may be a useful clinical test in the evaluation of renal insufficiency in cirrhotic patients with normal serum creatinine values. Many patients with cirrhosis and ascites will have a glomerular filtration rate of less than 60 ml/minute but a normal serum creatinine level. These patients may constitute a previously unrecognized large group.

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Owing to the characteristics of patients with LC, such as low muscle mass and high bilirubin level, the inadequacy of creatinine is intensified in these patients [5–7]. It is reported that sCr frequently overestimates kidney function in the cirrhotic population, particularly more often in patients with mild-to-moderate impairment, and is known to miscalculate the glomerular filtration rate up to 196% [7]. Furthermore, it may not be able to reveal mild renal dysfunction in a timely manner because as much as 75% reduction of the glomerular filtration rate might be needed for the condition to be reflected in sCr levels [18].
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Between May 2010 and October 2015, 1181 LT recipients (mean Model for End-stage Liver Disease score 12.1) with pretransplantation creatinine level ≤1.4 mg/dL were divided into tertiles according to each renal biomarker. The 30-day MACE was a composite of troponin I >0.2 ng/mL, arrhythmia, congestive heart failure, death, and cerebrovascular events.
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Citation Excerpt :
It is well established that serum Cr is not an accurate marker of renal dysfunction in cirrhosis.4–8
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: This work was supported by the Academic Senate Committee on Research, University of California, San Francisco, and the Research Service of the Veterans Administration Medical Center, San Francisco, California, and was presented in part at the 16th and 17th Annual Meetings, American Society of Nephrology, Washington, D.C., December 1983, and December 1984.

View full text

Unpredictability of clinical evaluation of renal function in cirrhosis: Prospective study

Abstract

Lancet

Am J Med

Am J Kidney Dis

Kidney Int

Am J Med

Clinical report on hydroperitoneum, based on analysis of forty-six cases

Am J Med Sci

The role of the kidney in Laennec's cirrhosis of the liver

Medicine

Acute hepatic necrosis with stupor or coma

Medicine

Salt retention in cirrhosis of the liver

J Clin Invest

Renal failure in Laennec's cirrhosis of the liver. I. Description of clinical and laboratory features

Ann Intern Med

Hepatorenal syndrome

Renal failure in terminal cirrhosis of the liver

Scand J Gastroenterol [Suppl]

Definition of hepatorenal syndrome

Renal failure in Laennec's cirrhosis. II

J Clin Invest

Renal function as a factor in fluid retention in patients with cirrhosis of the liver

J Clin Invest

Renal function changes in cirrhosis of the liver

Comparison of creatinine clearance to inulin clearance in the determination of glomerular filtration rate

J Urol