CRRT in Acute Liver Failure from Malignant Infiltration

Primary Considerations for CRRT Initiation

The American Association for the Study of Liver Diseases (AASLD) guidance explicitly states that RRT is not recommended as stand-alone therapy for hepatorenal syndrome-AKI unless patients are transplant candidates 1, 2
CRRT is primarily justified as a bridge to liver transplantation in patients with acute liver failure and AKI, as this represents the only definitive treatment with acceptable survival outcomes 1, 2

CRRT should be initiated when patients develop severe or refractory electrolyte abnormalities, particularly hyperkalemia, refractory acid-base imbalances, severe or refractory volume overload unresponsive to medical management, or symptomatic uremia 1, 2, 3, 4

The American Journal of Kidney Diseases recommends using continuous RRT rather than intermittent hemodialysis in these patients, as they are typically hemodynamically unstable 1, 2, 3, 5
CRRT provides superior cardiovascular stability and allows slower correction of severe hyponatremia, reducing neurological complications 3, 4
Target effluent volume of 20-25 mL/kg/hour 4, 5, 6
Mandatory use of bicarbonate-buffered (not lactate-buffered) dialysate and replacement fluids in liver failure patients, as this is a strong recommendation (1B evidence) because patients with liver failure have impaired lactate metabolism, and lactate-buffered solutions risk worsening lactic acidosis 4, 5, 7

The Journal of Hepatology suggests using SOFA and CLIF-SOFA scores for repeated risk stratification during treatment to guide ongoing decision-making 3

If patient has malignant infiltration causing acute liver failure, determine if they are a potential transplant candidate, and if not, strongly consider palliative care rather than CRRT 1, 2
Administer albumin 1 g/kg (maximum 100 g/day) for 48 hours, and for Stage 2 or greater HRS-AKI: initiate vasoconstrictors (terlipressin 0.5-2.0 mg IV q6h or norepinephrine) plus albumin 20-40 g/day 1, 2

Do not delay transplant evaluation in patients with HRS-AKI who are potential candidates; refer immediately 1, 2
Do not use lactate-buffered solutions in liver failure patients under any circumstances 4, 5, 7
Monitor for volume overload carefully, as these patients have impaired sodium and water handling 3, 4