Hepatorenal syndrome

Abstract

Hepatorenal syndrome (HRS) is defined as a functional renal failure in patients with liver disease with portal hypertension and it constitutes the climax of systemic circulatory changes associated with portal hypertension. This term refers to a precisely specified syndrome featuring in particular morphologically intact kidneys, where regulatory mechanisms have minimised glomerular filtration and maximised tubular resorption and urine concentration, which ultimately results in uraemia. The syndrome occurs almost exclusively in patients with ascites. Type 1 HRS develops as a consequence of a severe reduction of effective circulating volume due to both an extreme splanchnic arterial vasodilatation and a reduction of cardiac output. Type 2 HRS is characterised by a stable or slowly progressive renal failure so that its main clinical consequence is not acute renal failure, but refractory ascites, and its impact on prognosis is less negative. Liver transplantation is the most appropriate therapeutic method, nevertheless, only a few patients can receive it. The most suitable "bridge treatments" or treatment for patients ineligible for a liver transplant include terlipressin plus albumin. Terlipressin is at an initial dose of 0.5-1 mg every 4 h by intravenous bolus to 3 mg every 4 h in cases when there is no response. Renal function recovery can be achieved in less than 50% of patients and a considerable decrease in renal function may reoccur even in patients who have been responding to therapy over the short term. Transjugular intrahepatic portosystemic shunt plays only a marginal role in the treatment of HRS.

Predictors of hepatorenal syndrome in alcoholic liver cirrhosis

“…Hepatorenal syndrome is a potentially preventable, but serious complication of advanced liver cirrhosis 14 . Although several complex predictive tools exist for mortality of liver cirrhosis and its complications, no such tool is available for hepatorenal syndrome.…”

Renal dysfunction in patients with cirrhosis: Where do we stand?

“…High level of suspicion is needed regarding the spontaneous bacterial peritonitis since infections very common trigger HRS. Moreover, albumin infusions will correct hypoalbuminemia and partial ascites evacuation will alleviate circulation [33,74] . In the setting of alcohol-related cirrhosis and ascites, the intestinal decontamination with rifaximin may also improve systemic hemodynamics and renal function [75] .…”

“…If patient respond, some centers continue therapy with midodrine (an oral α1-adrenergic agonist with vasoconstrictive properties) indefinitely to keep higher MAP and to compensate refractory ascites [94] . If there is no improvement in renal function after two weeks, the protocol maybe repeated -there have been reports for protocol administration up to eight months [9,74,95,96] -or other interventional options are applied regarding the patient status and the available treatment options of the centre. Moreover, changes on terlipressin administration modality (given as continuous infusion instead of iv pulses) accounted for enhancement of its efficacy [5,97] (Table 6).…”

“…In patients with HRS 1, preliminary studies [108,111] about TIPS showed improvement of renal function in parallel with survival, but it cannot be applied in clinical practice yet as a main treatment. At present, TIPS can be used in selected patients without severe liver dysfunction as a bridge for LT or in patients with stabilized liver function not enlisted, as a long term -therapy [74] (Table 5). Table 6 Scheme for terlipressin and albumin administration [5,97] Terlipressin is given as an intravenous bolus 1 to 2 mg every four to six hours Albumin is given for two days as an intravenous bolus 1 g/kg per day (100 g maximum) followed by 25 to 50 g /d until terlipressin therapy is discontinued Table 7 Published guidelines on selection criteria for simultaneous liver-kidney transplantation…”

Clinical Profile of Hepatorenal Syndrome

“…Type 2 hepatorenal syndrome is characterized by moderate and stable reduction in the glomerular filteration rate (with serum creatinine increasing to greater than 1.5 mg/dl or creatinine clearance less than 40ml/min). [4,5] It most commonly occurs in patients with relatively preserved hepatic function. Median survival rate is 3-6 months.…”