Renal dysfunction in cirrhosis is characterized by seemingly inappropriate avid retention of sodium and free water together with renal hypoperfusion and consequent decreased glomerular filtration.

1. The extreme manifestation of this is the hepatorenal syndrome (HRS), a prerenal functional abnormality that is the renal response to the circulatory abnormalities of advanced cirrhosis (Fig. 45-2: The pathogenetic mechanism of the hepatorenal syndrome).
   1. Type I HRS is characterized by rapidly progressive renal failure, typically represented by at least a doubling of serum creatinine over the course of 2 weeks in close proximity to a precipitating cause such as spontaneous bacterial peritonitis, sepsis, gastrointestinal bleeding, or surgical stress.
      1. Patients with type I HRS have a median survival time of 2 to 4 weeks without therapy.
      2. When patient with type I HRS respond to medical therapy, the response is usually sustained.
   2. Type II HRS is more indolent and may be considered the expected consequence of continuous and progressive activity of the circulatory homeostatic triad of the sympathetic, renin–angiotensin–aldosterone, and vasopressin systems in an attempt to compensate for the progressive loss of effective circulating blood volume to the increasingly dilated splanchnic vasculature.
      1. The most compelling clinical problem in these patients is refractory ascites.
      2. Patients with type II HRS have a median survival time of about 6 months.
   3. Liver transplantation is the definitive therapy for HRS. For patients with HRS who are transplant candidates, renal replacement therapy is the typical bridge to transplantation.
2. Renal function is an important risk factor for mortality.
3. The cirrhotic circulatory system is characterized by marked sympathetic stimulation and activation of the renin–angiotensin–aldosterone and vasopressin systems. These combine to save salt and water and reduce renal perfusion.
4. Cirrhotic patients are at risk for hypovolemia from a number of causes, including gastrointestinal bleeding, diuretic use, and diarrhea resulting from lactulose or rifaximin administration.

The Liver: Surgery and Anesthesia

1. Assessment of Hepatic Function
2. Hepatobiliary Imaging
3. Liver Biopsy
4. Hepatic and Hepatobiliary Diseases
5. Acute Liver Failure
6. Acute Hepatitis
7. Alcoholic Hepatitis
8. Drug-Induced Liver Injury
9. Pregnancy-Related Liver Diseases
10. Cirrhosis and Portal Hypertension
11. Hemostasis
12. Cardiac Manifestations
13. Renal Dysfunction
14. Pulmonary Complications
15. Hepatic Encephalopathy (HE)
16. Ascites
17. Varices
18. Chronic Cholestatic Disease
19. Chronic Hepatocellular Disease
20. Hepatocellular Carcinoma (HCC)
21. Nonalcoholic Fatty Liver Disease
22. Preoperative Management
23. Intraoperative Management
24. Transjugular Intrahepatic Portosystemic Shunt Procedure
25. Hepatic Resection
26. Postoperative Liver Dysfunction