Speaker discusses acute kidney injury with hepatorenal syndrome, acetaminophen overdose
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A speaker at the American Nephrology Nurses Association’s Nephrology Nursing Practice, Management & Leadership Conference discussed the development of AKI in patients who have hepatorenal syndrome or who use acetaminophen therapies.
Mary Schira, PhD, APRN, ACNP-BC, from the student success faculty at The University of Texas at Arlington College of Nursing and Health Innovation, said that although hepatorenal syndrome is not very common, it is important for nephrology nurses to have a fuller understanding of the condition because it carries a high mortality risk and is the fifth cause of AKI worldwide. She also noted that approximately 20% of individuals with advanced cirrhosis will develop some degree of hepatorenal syndrome in about a year of being diagnosed.
Link between cirrhosis, hepatorenal syndrome and AKI
“When a patient becomes decompensated with their cirrhosis, they are much more likely to develop hepatorenal syndrome because that decompensation makes them hemodynamically unstable,” Schira said. “When we think about hepatorenal syndrome, we want to remember that this is a functional kidney failure due to liver cirrhosis. It’s not an intrinsic kidney failure.”
Schira explained that this type of kidney failure arises from the changes in circulation to the kidneys from when the liver undergoes decompensated cirrhosis. According to Schira, these changes in circulation to the kidneys occur because the compensatory mechanisms become overwhelmed.
“We know how stellar our kidneys are at being able to compensate and cope and do wonderful things, but there comes a point that they simply can’t continue to compensate for what’s happening in the overall circulation. And when those compensatory mechanisms become overwhelmed, there’s going to be a decrease in the glomerular filtration rate just as we see in any acute or chronic kidney injury,” she said, adding that there will also be less creatinine in these patients because the liver makes creatine, which is then stored in the muscle and converted to creatinine.
Schira said it is essential for nurses, especially those who work with patients who have high acuity needs, to understand this link between liver failure, acute kidney injury and, potentially, chronic kidney disease.
Acetaminophen, liver failure and AKI
In addition to hepatorenal syndrome and AKI, Schira touched on the role of acetaminophen in AKI. Here, she contended that while nephrotoxicity from the medication resulting in AKI is uncommon, the potential for AKI with overuse must be kept on the nephrology nurse’s radar due to the frequency with which acetaminophen-based medications are used.
“Acetaminophen can cause an acute liver failure and, as a result, can then cause an acute kidney injury,” she said. “The reason I wanted to bring this to your radar is that, as we know, acetaminophen is an extremely common analgesic in individuals with CKD and is very common in elders. It’s our go to analgesic. It’s also a component of a lot of over-the-counter medications, either just by itself or in combination. It’s in our sinus medicines. It’s in our flu medicines. It’s in everything.”
Schira reminded the audience that while the standard maximum daily dose of the medication is 4 g for adults, if a patient has been using acetaminophen at “fairly high doses” for over a week or if they are older or have malnutrition, the maximum daily dose is 3 g; if the patient already has liver disease, according to Schira, they should not take more than 2 g daily.
Overdose occurs when an adult takes between 7 and 10 g of acetaminophen in a day, she said.
“Keep your antenna up for this either as an intentional overdose or an unintentional overdose [that happens when] someone’s arthritis has been bothering them and they have taken entirely too much,” she said.
In the event of an overdose, Schira suggested treating patients with activated charcoal. N-acetyl cysteine, which Schria explained replenishes glutathione, can also be used but must be given within the first 8 hours.
Regarding interventions nephrology nurses can take for patients with liver complications who are at risk for AKI, Schira recommends closely monitoring liver function (including liver enzymes, bilirubin and coagulation factors) and kidney function (including creatinine and cellular biomarkers), as well as coordinating care and providing psychosocial support to patients and their families.
“These patients are complex, and your role is important,” Schira said.
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Schira M. Liver failure and chronic kidney disease. Presented at: American Nephrology Nurses Association’s Nephrology Nursing Practice, Management & Leadership Conference. Sept. 16-19, 2021 (virtual meeting).
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