Hepatorenal syndrome in patients with cirrhosis

Abstract

Type 1 hepatorenal syndrome (HRS) is a severe complication of end-stage cirrhosis. Type 1 HRS is an acute functional renal failure (i.e. glomerular hypofiltration) with no other explanation than the presence of the circulatory and neurohumoral alterations associated with severe chronic liver disease. Plasma volume expansion does not improve renal function. In contrast, administration of the vasopressin analog terlipressin, a splanchnic and systemic vasoconstrictor, may improve renal function and be used while awaiting liver transplantation. © 2002 Blackwell Publishing Asia Pty LtdKey words : cirrhosis, renal failure, vasoconstrictors. DEFINITIONS AND DIAGNOSISHepatorenal syndrome (HRS) is a renal failure which complicates end-stage cirrhosis with ascites. [1][2][3][4][5] There are two clinical types of HRS: type 1 and 2. 2 Type 1 HRS is characterized by the development of acute renal failure; that is, a doubling of initial serum creatinine to levels above 130 µ mol/L or a 50% decrease in the initial 24-h creatinine clearance to below 20 mL/min in less than 2 weeks. 2 Patients with type 1 HRS are in poor condition. Type 2 HRS is characterized by moderate and stable renal failure in patients who have a better condition than those with type 1 HRS. 2 This review will focus on the mechanisms, diagnosis, prognosis and treatment of type 1 HRS, and the term HRS will be used instead of type 1 HRS.Information on the frequency of HRS is controversial. In a large North American study of 3860 patients with ascites, HRS was diagnosed in less than 1% of patients. 6 Another study of 234 non-azotemic patients with ascites showed that the probability of developing HRS was 20% and 40% at 1 and 5 years, respectively. 7

A Randomized, Prospective, Double-Blind, Placebo-Controlled Trial of Terlipressin for Type 1 Hepatorenal Syndrome

“…28,29 However, not all subjects are candidates for liver transplantation, and liver transplantation is not universally available. In those who are transplant candidates, a suitable organ often cannot be found in time, and, even when an organ is available, the presence of uncorrected HRS type 1 worsens the outcomes of liver transplantation.…”

The use of vasoconstrictors in patients with cirrhosis: Type 1 HRS and beyond

“…16 HRS is a life-threatening complication of cirrhosis. [17][18][19][20][21][22][23] ; the spontaneous median survival time is less than 2 weeks and the probability of survival at 1 month is very low (25%). 17 Liver transplantation is the only treatment that can cure end-stage cirrhosis.…”

“…17 Liver transplantation is the only treatment that can cure end-stage cirrhosis. [18][19][20][21][22] However, patients who undergo transplantation with HRS have a lower probability of postoperative survival and a higher probability of developing postoperative complications than patients without HRS. 20,21 Therefore, measures that bridge patients to liver transplantation are needed.…”

“…In addition, treatment for HRS is also needed for patients who are not candidates for liver transplantation. 20 The ideal treatment of type 1 HRS must fulfill at least three aims. 20 First, it should induce reversal of HRS defined as a decrease in serum creatinine levels below 133 mol/L (1.5 mg/dL).…”

“…20 The ideal treatment of type 1 HRS must fulfill at least three aims. 20 First, it should induce reversal of HRS defined as a decrease in serum creatinine levels below 133 mol/L (1.5 mg/dL). Second, there should be a slight prolongation of survival, which may increase the chance of receiving a liver transplant in appropriate candidates.…”