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Working Party proposal for a revised classification system of renal dysfunction in patients with cirrhosis | Gut
<?xml version="1.0" encoding="UTF-8"?><!DOCTYPE html> <html lang="en" dir="ltr" version="HTML+RDFa+MathML 1.1" xmlns:dc="http://purl.org/dc/terms/" xmlns:foaf="http://xmlns.com/foaf/0.1/" xmlns:og="http://ogp.me/ns#" xmlns:rdfs="http://www.w3.org/2000/01/rdf-schema#" xmlns:sioc="http://rdfs.org/sioc/ns#" xmlns:sioct="http://rdfs.org/sioc/types#" xmlns:skos="http://www.w3.org/2004/02/skos/core#" xmlns:xsd="http://www.w3.org/2001/XMLSchema#" xmlns:mml="http://www.w3.org/1998/Math/MathML"> <head profile="http://www.w3.org/1999/xhtml/vocab"> <!--[if IE]><![endif]--> <link rel="dns-prefetch" href="//securepubads.g.doubleclick.net" /> <link rel="dns-prefetch" href="//d1bxh8uas1mnw7.cloudfront.net" /> <link rel="dns-prefetch" href="//scholar.google.com" /> <meta http-equiv="Content-Type" content="text/html; charset=utf-8" /> <link rel="shortcut icon" href="https://gut.bmj.com/sites/default/themes/bmjj/favicon.ico" type="image/vnd.microsoft.icon" /> <meta name="viewport" content="width=device-width, initial-scale=1" /> <script>window.dataLayer = window.dataLayer || [];window.dataLayer.push({"page":{"hwTitle":"Working Party proposal for a revised classification system of renal dysfunction in patients with cirrhosis","hwUrl":"https://gut.bmj.com/content/60/5/702","hwPath":"/content/60/5/702.short","hwType":"journal page"},"user":{"hwMemberID":"","hwLoggedIntoInstitutionID":"","hwLoggedIntoInstitution":"","hwAccessUsageTerms":"guest","hwRegisteredUser":"no","hwHasFullTextAccess":"yes","hwEntitled":"no","mail":"e3b0c44298fc1c149afbf4c8996fb92427ae41e4649b934ca495991b7852b855"},"content":{"hwIssueDate":"2011-05-01","hwIssueDateTime":"2011-05-01 00:00:00","hwPublicationDate":"2017-10-26","hwPublicationDateTime":"2017-10-26 03:59:25","hwNlmArticleType":"research-article","hwDOI":"10.1136/gut.2010.236133","hwAuthors":"Florence Wong,Mitra K Nadim,John A Kellum,Francesco Salerno,Rinaldo Bellomo,Alexander Gerbes,Paolo Angeli,Richard Moreau,Andrew Davenport,Rajiv Jalan,Claudio Ronco,Yuri Genyk,Vicente Arroyo","hwContributors":"","hwIsEarlyRelease":"no","hwEissn":"1468-3288","hwPissn":"0017-5749","hwVolume":"60","hwIssue":"5","hwArticleType":"Hepatology","hwTabView":"main_tab","hwViewType":"short","hwAccessType":"Free","hwOpenAccess":"no","hwFreeAccess":"yes","hwTaxonomy":"Editor's choice","hwCorpusCode":"gutjnl","hwType":"article","hwSubtitle":null,"hwOverline":null,"hwPisaId":"gutjnl;60/5/702","hwFirstPage":"702","hwLastPage":"709","hwIsLatestVersion":"yes","hwIsCurrentIssue":"no","hwIsOpenIssue":"no","hwHasFullText":"yes","hwHasPDF":"yes","hwParentTitle":"Gut: 60 (5)","hwElectronicPubDate":"2017-10-26","hwElectronicPubDateTime":"2017-10-26 03:59:25"}}); //--><!]]></script> <link rel="canonical" href="https://gut.bmj.com/content/60/5/702" /> <meta name="Generator" content="Drupal 7 (http://drupal.org)" /> <link rel="alternate" type="application/pdf" title="Full Text (PDF)" href="/content/60/5/702.full.pdf" /> <link rel="alternate" type="text/plain" title="Full Text (Plain)" href="/content/60/5/702.full.txt" /> <meta name="issue_cover_image" content="https://gut.bmj.com/sites/default/files/highwire/gutjnl/60/5.cover.gif" /> <meta name="type" content="article" /> <meta name="category" content="research-article" /> <meta name="HW.identifier" content="/gutjnl/60/5/702.atom" /> <meta name="HW.pisa" content="gutjnl;60/5/702" /> <meta name="DC.Format" content="text/html" /> <meta name="DC.Language" content="en" /> <meta name="DC.Title" content="Working Party proposal for a revised classification system of renal dysfunction in patients with cirrhosis" /> <meta name="DC.Identifier" content="10.1136/gut.2010.236133" /> <meta name="DC.Date" content="2011-05-01" /> <meta name="DC.Publisher" content="BMJ Publishing Group" /> <meta name="DC.Rights" content="© 2011, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions." /> <meta name="DC.AccessRights" content="restricted" /> <meta name="DC.Relation" content="10.1136/gut.2011.242479" /> <meta name="DC.Description" content="Objectives To propose an improvement on the current classification of renal dysfunction in cirrhosis. Clinicians caring for patients with cirrhosis recognize that the development of renal dysfunction is associated with significant morbidity and mortality. While most cases of renal dysfunction in cirrhosis are functional in nature, developed as a result of changes in haemodynamics, cardiac function, and renal auto-regulation, there is an increasing number of patients with cirrhosis and structural changes in their kidney as a cause of renal dysfunction. Therefore, there is a need for a newer classification to include both functional and structural renal diseases. Design A working party consisting of specialists from multiple disciplines conducted literature search and developed summary statements, incorporating the renal dysfunction classification used in nephrology. These were discussed and revised to produce this proposal. Setting Multi-disciplinary international meeting. Patients None. Interventions Literature search using keywords of cirrhosis, renal dysfunction, acute kidney injury (AKI), chronic kidney injury (CKD), and hepatorenal syndrome. Results Acute kidney injury will include all causes of acute deterioration of renal function as indicated by an increase in serum creatinine of >50% from baseline, or a rise in serum creatinine of ≥26.4µmol/L (≥0.3mg/dL) in <48hours. Chronic renal disease will be defined as an estimated glomerular filtration rate (GFR) of <60ml/min calculated using the Modification of Diet in Renal Disease 6 (MDRD6) formula, recognising that the MDRD6 formula is not perfect for the cirrhotic patients and this may change as improved means of estimating GFR becomes available. Acute on chronic kidney disease will be defined as AKI superimposed on existing chronic renal disease using the above definitions for AKI and CKD. Conclusions Accepting this new classification will allow studies into the epidemiology, incidence, prevalence, natural history and the development of new treatments for these subtypes of renal dysfunction in cirrhosis." /> <meta name="DC.Contributor" content="Florence Wong" /> <meta name="DC.Contributor" content="Mitra K Nadim" /> <meta name="DC.Contributor" content="John A Kellum" /> <meta name="DC.Contributor" content="Francesco Salerno" /> <meta name="DC.Contributor" content="Rinaldo Bellomo" /> <meta name="DC.Contributor" content="Alexander Gerbes" /> <meta name="DC.Contributor" content="Paolo Angeli" /> <meta name="DC.Contributor" content="Richard Moreau" /> <meta name="DC.Contributor" content="Andrew Davenport" /> <meta name="DC.Contributor" content="Rajiv Jalan" /> <meta name="DC.Contributor" content="Claudio Ronco" /> <meta name="DC.Contributor" content="Yuri Genyk" /> <meta name="DC.Contributor" content="Vicente Arroyo" /> <meta name="article:published_time" content="2011-05-01" /> <meta name="article:section" content="Hepatology" /> <meta name="citation_title" content="Working Party proposal for a revised classification system of renal dysfunction in patients with cirrhosis" /> <meta name="citation_abstract" lang="en" content="<h3>Objectives</h3> <p>To propose an improvement on the current classification of renal dysfunction in cirrhosis. Clinicians caring for patients with cirrhosis recognize that the development of renal dysfunction is associated with significant morbidity and mortality. While most cases of renal dysfunction in cirrhosis are functional in nature, developed as a result of changes in haemodynamics, cardiac function, and renal auto-regulation, there is an increasing number of patients with cirrhosis and structural changes in their kidney as a cause of renal dysfunction. Therefore, there is a need for a newer classification to include both functional and structural renal diseases.</p><h3>Design</h3> <p>A working party consisting of specialists from multiple disciplines conducted literature search and developed summary statements, incorporating the renal dysfunction classification used in nephrology. These were discussed and revised to produce this proposal.</p><h3>Setting</h3> <p>Multi-disciplinary international meeting.</p><h3>Patients</h3> <p>None.</p><h3>Interventions</h3> <p>Literature search using keywords of cirrhosis, renal dysfunction, acute kidney injury (AKI), chronic kidney injury (CKD), and hepatorenal syndrome.</p><h3>Results</h3> <p>Acute kidney injury will include all causes of acute deterioration of renal function as indicated by an increase in serum creatinine of &gt;50% from baseline, or a rise in serum creatinine of ≥26.4µmol/L (≥0.3mg/dL) in &lt;48hours. Chronic renal disease will be defined as an estimated glomerular filtration rate (GFR) of &lt;60ml/min calculated using the Modification of Diet in Renal Disease 6 (MDRD6) formula, recognising that the MDRD6 formula is not perfect for the cirrhotic patients and this may change as improved means of estimating GFR becomes available. Acute on chronic kidney disease will be defined as AKI superimposed on existing chronic renal disease using the above definitions for AKI and CKD.</p><h3>Conclusions</h3> <p>Accepting this new classification will allow studies into the epidemiology, incidence, prevalence, natural history and the development of new treatments for these subtypes of renal dysfunction in cirrhosis.</p>" /> <meta name="citation_journal_title" content="Gut" /> <meta name="citation_publisher" content="BMJ Publishing Group" /> <meta name="citation_publication_date" content="2011/05/01" /> <meta name="citation_mjid" content="gutjnl;60/5/702" /> <meta name="citation_id" content="60/5/702" /> <meta name="citation_public_url" content="https://gut.bmj.com/content/60/5/702" /> <meta name="citation_abstract_html_url" content="https://gut.bmj.com/content/60/5/702.abstract" /> <meta name="citation_full_html_url" content="https://gut.bmj.com/content/60/5/702.full" /> <meta name="citation_pdf_url" content="https://gut.bmj.com/content/gutjnl/60/5/702.full.pdf" /> <meta name="citation_issn" content="0017-5749" /> <meta name="citation_issn" content="1468-3288" /> <meta name="citation_doi" content="10.1136/gut.2010.236133" /> <meta name="citation_pmid" content="21325171" /> <meta name="citation_volume" content="60" /> <meta name="citation_issue" content="5" /> <meta name="citation_article_type" content="Research Article" /> <meta name="citation_section" content="Hepatology" /> <meta name="citation_firstpage" content="702" /> <meta name="citation_lastpage" content="709" /> <meta name="citation_author" content="Florence Wong" /> <meta name="citation_author" content="Mitra K Nadim" /> <meta name="citation_author" content="John A Kellum" /> <meta name="citation_author" content="Francesco Salerno" /> <meta name="citation_author" content="Rinaldo Bellomo" /> <meta name="citation_author" content="Alexander Gerbes" /> <meta name="citation_author" content="Paolo Angeli" /> <meta name="citation_author" content="Richard Moreau" /> <meta name="citation_author" content="Andrew Davenport" /> <meta name="citation_author" content="Rajiv Jalan" /> <meta name="citation_author" content="Claudio Ronco" /> <meta name="citation_author" content="Yuri Genyk" /> <meta name="citation_author" content="Vicente Arroyo" /> <meta name="citation_reference" content="citation_journal_title=Hepatology (Baltimore, Md.);citation_journal_abbrev=Hepatology;citation_author=G. 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Gerbes;citation_title=TIPS for the treatment of refractory ascites, hepatorenal syndrome and hepatic hydrothorax: a critical update;citation_pages=988-1000;citation_volume=59;citation_year=2010;citation_issue=7;citation_issn=0017-5749;citation_pmid=20581246;citation_doi=10.1136/gut.2009.193227" /> <meta name="twitter:title" content="Working Party proposal for a revised classification system of renal dysfunction in patients with cirrhosis" /> <meta name="twitter:card" content="summary_large_image" /> <meta name="twitter:image" content="https://gut.bmj.com/sites/default/files/highwire/gutjnl/60/5.cover.gif" /> <meta name="twitter:description" content="Objectives To propose an improvement on the current classification of renal dysfunction in cirrhosis. Clinicians caring for patients with cirrhosis recognize that the development of renal dysfunction is associated with significant morbidity and mortality. While most cases of renal dysfunction in cirrhosis are functional in nature, developed as a result of changes in haemodynamics, cardiac function, and renal auto-regulation, there is an increasing number of patients with cirrhosis and structural changes in their kidney as a cause of renal dysfunction. Therefore, there is a need for a newer classification to include both functional and structural renal diseases. Design A working party consisting of specialists from multiple disciplines conducted literature search and developed summary statements, incorporating the renal dysfunction classification used in nephrology. These were discussed and revised to produce this proposal. Setting Multi-disciplinary international meeting. Patients None. Interventions Literature search using keywords of cirrhosis, renal dysfunction, acute kidney injury (AKI), chronic kidney injury (CKD), and hepatorenal syndrome. Results Acute kidney injury will include all causes of acute deterioration of renal function as indicated by an increase in serum creatinine of >50% from baseline, or a rise in serum creatinine of ≥26.4µmol/L (≥0.3mg/dL) in <48hours. Chronic renal disease will be defined as an estimated glomerular filtration rate (GFR) of <60ml/min calculated using the Modification of Diet in Renal Disease 6 (MDRD6) formula, recognising that the MDRD6 formula is not perfect for the cirrhotic patients and this may change as improved means of estimating GFR becomes available. Acute on chronic kidney disease will be defined as AKI superimposed on existing chronic renal disease using the above definitions for AKI and CKD. Conclusions Accepting this new classification will allow studies into the epidemiology, incidence, prevalence, natural history and the development of new treatments for these subtypes of renal dysfunction in cirrhosis." /> <meta name="og-title" property="og:title" content="Working Party proposal for a revised classification system of renal dysfunction in patients with cirrhosis" /> <meta name="og-url" property="og:url" content="https://gut.bmj.com/content/60/5/702" /> <meta name="og-site-name" property="og:site_name" content="Gut" /> <meta name="og-description" property="og:description" content="Objectives To propose an improvement on the current classification of renal dysfunction in cirrhosis. Clinicians caring for patients with cirrhosis recognize that the development of renal dysfunction is associated with significant morbidity and mortality. While most cases of renal dysfunction in cirrhosis are functional in nature, developed as a result of changes in haemodynamics, cardiac function, and renal auto-regulation, there is an increasing number of patients with cirrhosis and structural changes in their kidney as a cause of renal dysfunction. Therefore, there is a need for a newer classification to include both functional and structural renal diseases. Design A working party consisting of specialists from multiple disciplines conducted literature search and developed summary statements, incorporating the renal dysfunction classification used in nephrology. These were discussed and revised to produce this proposal. Setting Multi-disciplinary international meeting. Patients None. Interventions Literature search using keywords of cirrhosis, renal dysfunction, acute kidney injury (AKI), chronic kidney injury (CKD), and hepatorenal syndrome. Results Acute kidney injury will include all causes of acute deterioration of renal function as indicated by an increase in serum creatinine of >50% from baseline, or a rise in serum creatinine of ≥26.4µmol/L (≥0.3mg/dL) in <48hours. Chronic renal disease will be defined as an estimated glomerular filtration rate (GFR) of <60ml/min calculated using the Modification of Diet in Renal Disease 6 (MDRD6) formula, recognising that the MDRD6 formula is not perfect for the cirrhotic patients and this may change as improved means of estimating GFR becomes available. Acute on chronic kidney disease will be defined as AKI superimposed on existing chronic renal disease using the above definitions for AKI and CKD. Conclusions Accepting this new classification will allow studies into the epidemiology, incidence, prevalence, natural history and the development of new treatments for these subtypes of renal dysfunction in cirrhosis." /> <meta name="og-type" property="og:type" content="article" /> <meta name="og-image" property="og:image" content="https://gut.bmj.com/sites/default/files/highwire/gutjnl/60/5.cover.gif" /> <link rel="alternate" type="application/vnd.ms-powerpoint" title="Powerpoint" href="/content/60/5/702.ppt" /> <title>Working Party proposal for a revised classification system of renal dysfunction in patients with cirrhosis | Gut</title> <link type="text/css" rel="stylesheet" href="/sites/default/files/advagg_css/css__SXdRkZmI6sImeXD-jEGdZfrJy7g85hSv3_c89En08-8__BkUQ0yKymMbiRZNLbV7c1Pg0jmMBE1pa-Dap8Tr0rIU__dGRtyN8GJBuhBvXCmXEhVK4mGQl3ZIewHeJUeSvfyQ0.css" media="all" /> <!-- OneTrust Cookies Consent Notice start --> <script 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class="contributor" id="contrib-4"><span class="name">Francesco Salerno</span><a id="xref-aff-4-1" class="xref-aff" href="#aff-4">4</a>, </li><li class="contributor" id="contrib-5"><span class="name">Rinaldo Bellomo</span><a id="xref-aff-5-1" class="xref-aff" href="#aff-5">5</a>, </li><li class="contributor" id="contrib-6"><span class="name">Alexander Gerbes</span><a id="xref-aff-6-1" class="xref-aff" href="#aff-6">6</a>, </li><li class="contributor" id="contrib-7"><span class="name">Paolo Angeli</span><a id="xref-aff-7-1" class="xref-aff" href="#aff-7">7</a>, </li><li class="contributor" id="contrib-8"><span class="name">Richard Moreau</span><a id="xref-aff-8-1" class="xref-aff" href="#aff-8">8</a>, </li><li class="contributor" id="contrib-9"><span class="name">Andrew Davenport</span><a id="xref-aff-9-1" class="xref-aff" href="#aff-9">9</a>, </li><li class="contributor" id="contrib-10"><span class="name">Rajiv Jalan</span><a id="xref-aff-10-1" class="xref-aff" href="#aff-10">10</a>, </li><li class="contributor" id="contrib-11"><span class="name">Claudio Ronco</span><a id="xref-aff-11-1" class="xref-aff" href="#aff-11">11</a>, </li><li class="contributor" id="contrib-12"><span class="name">Yuri Genyk</span><a id="xref-aff-12-1" class="xref-aff" href="#aff-12">12</a>, </li><li class="last" id="contrib-13"><span class="name">Vicente Arroyo</span><a id="xref-aff-13-1" class="xref-aff" href="#aff-13">13</a></li></ol><ol class="affiliation-list"><li class="aff"><a id="aff-1" name="aff-1"></a><address><sup>1</sup>Department of Medicine, University of Toronto, Toronto, Canada</address></li><li class="aff"><a id="aff-2" name="aff-2"></a><address><sup>2</sup>Division of Nephrology, University of Southern California, Los Angeles, California, USA</address></li><li class="aff"><a id="aff-3" name="aff-3"></a><address><sup>3</sup>Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA</address></li><li class="aff"><a id="aff-4" name="aff-4"></a><address><sup>4</sup>Policlinico IRCCS San Donato and Dipartimento di Scienze Medico-Chirurgiche, Università di Milano, Milano, Italy</address></li><li class="aff"><a id="aff-5" name="aff-5"></a><address><sup>5</sup>Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia</address></li><li class="aff"><a id="aff-6" name="aff-6"></a><address><sup>6</sup>Liver Center Munich, Klinikum München-Grosshadern, Ludwig-Maximilians-Universität München, München, Germany</address></li><li class="aff"><a id="aff-7" name="aff-7"></a><address><sup>7</sup>Department of Clinical and Experimental Medicine, University of Padova, Padova, Italy</address></li><li class="aff"><a id="aff-8" name="aff-8"></a><address><sup>8</sup>Centre de Recherche Biomédicale Bichat-Beaujon, Service d'Hépatologie, Hôpital Beaujon, Clichy, France</address></li><li class="aff"><a id="aff-9" name="aff-9"></a><address><sup>9</sup>Centre for Nephrology, University College London Medical School, London, UK</address></li><li class="aff"><a id="aff-10" name="aff-10"></a><address><sup>10</sup>Institute of Hepatology, University College London Medical School, London, UK</address></li><li class="aff"><a id="aff-11" name="aff-11"></a><address><sup>11</sup>Division of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy</address></li><li class="aff"><a id="aff-12" name="aff-12"></a><address><sup>12</sup>Division of Multiorgan Abdominal Transplantation, University of Southern California, Los Angeles, California, USA</address></li><li class="aff"><a id="aff-13" name="aff-13"></a><address><sup>13</sup>Liver Unit, Institute of Digestive and Metabolic Diseases, Hospital Clinic, University of Barcelona, Spain</address></li></ol><ol class="corresp-list"><li class="corresp" id="corresp-1"><span class="corresp-label">Correspondence to</span> Florence Wong, 9N/983, Department of Medicine, Toronto General Hospital, University of Toronto, 200 Elizabeth Street, Toronto, Ontario M5G2C4, Canada; <span class="em-link"><span class="em-addr">florence.wong{at}utoronto.ca</span></span></li></ol></div></div></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-highwire-markup abstract-with-bc" > <div class="pane-content"> <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" id="content-block" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article abstract-view"><span class="highwire-journal-article-marker-start"></span><div class="section abstract" id="abstract-1"><h2>Abstract</h2><div id="sec-1" class="subsection"><p id="p-1"><strong>Objectives</strong> To propose an improvement on the current classification of renal dysfunction in cirrhosis. Clinicians caring for patients with cirrhosis recognize that the development of renal dysfunction is associated with significant morbidity and mortality. While most cases of renal dysfunction in cirrhosis are functional in nature, developed as a result of changes in haemodynamics, cardiac function, and renal auto-regulation, there is an increasing number of patients with cirrhosis and structural changes in their kidney as a cause of renal dysfunction. Therefore, there is a need for a newer classification to include both functional and structural renal diseases.</p></div><div id="sec-2" class="subsection"><p id="p-2"><strong>Design</strong> A working party consisting of specialists from multiple disciplines conducted literature search and developed summary statements, incorporating the renal dysfunction classification used in nephrology. These were discussed and revised to produce this proposal.</p></div><div id="sec-3" class="subsection"><p id="p-3"><strong>Setting</strong> Multi-disciplinary international meeting.</p></div><div id="sec-4" class="subsection"><p id="p-4"><strong>Patients</strong> None.</p></div><div id="sec-5" class="subsection"><p id="p-5"><strong>Interventions</strong> Literature search using keywords of cirrhosis, renal dysfunction, acute kidney injury (AKI), chronic kidney injury (CKD), and hepatorenal syndrome.</p></div><div id="sec-6" class="subsection"><p id="p-6"><strong>Results</strong> Acute kidney injury will include all causes of acute deterioration of renal function as indicated by an increase in serum creatinine of >50% from baseline, or a rise in serum creatinine of ≥26.4µmol/L (≥0.3mg/dL) in <48hours. Chronic renal disease will be defined as an estimated glomerular filtration rate (GFR) of <60ml/min calculated using the Modification of Diet in Renal Disease 6 (MDRD6) formula, recognising that the MDRD6 formula is not perfect for the cirrhotic patients and this may change as improved means of estimating GFR becomes available. Acute on chronic kidney disease will be defined as AKI superimposed on existing chronic renal disease using the above definitions for AKI and CKD.</p></div><div id="sec-7" class="subsection"><p id="p-7"><strong>Conclusions</strong> Accepting this new classification will allow studies into the epidemiology, incidence, prevalence, natural history and the development of new treatments for these subtypes of renal dysfunction in cirrhosis.</p></div></div><ul class="kwd-group"><li class="kwd">Acute kidney injury</li><li class="kwd">chronic kidney disease</li><li class="kwd">cirrhosis</li><li class="kwd">creatinine</li><li class="kwd">hepatorenal syndrome</li><li class="kwd">renal dysfunction</li><li class="kwd">liver cirrhosis</li></ul><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-dfp-pane oas-ads oas-ads-mid pull-right" > <div class="pane-content"> <div id="dfp-ad-mpu-wrapper" class="dfp-tag-wrapper"> <div id="dfp-ad-mpu" class="dfp-tag-wrapper"> <script type="text/javascript"> googletag.cmd.push(function() { googletag.display("dfp-ad-mpu"); }); </script> </div> </div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-custom pane-2" > <div class="pane-content"> <p><a href="https://doi.org/10.1136/gut.2010.236133" target="_new">https://doi.org/10.1136/gut.2010.236133</a></p> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-highwire-altmetrics" > <h2 class="pane-title">Statistics from Altmetric.com</h2> <div class="pane-content"> <div data-badge-details="right" data-badge-type="medium-donut" data-doi="10.1136/gut.2010.236133" data-hide-no-mentions="true" class="altmetric-embed"></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-bmjj-jumplinks" > <div class="pane-content"> <div class="highwire-list-wrapper"><div class="highwire-list"><ul></ul></div></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-custom pane-3 permissions-box" > <h2 class="pane-title">Request Permissions</h2> <div class="pane-content"> <p>If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. 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