Hepatorenal syndrome: the 8th international consensus conference of the Acute Dialysis Quality Initiative (ADQI) group

Abstract

IntroductionRenal dysfunction is a common complication in patients with end-stage cirrhosis. Since the original publication of the definition and diagnostic criteria for the hepatorenal syndrome (HRS), there have been major advances in our understanding of its pathogenesis. The prognosis of patients with cirrhosis who develop HRS remains poor, with a median survival without liver transplantation of less than six months. However, a number of pharmacological and other therapeutic strategies have now become available which offer the ability to prevent or treat renal dysfunction more effectively in this setting. Accordingly, we sought to review the available evidence, make recommendations and delineate key questions for future studies.MethodsWe undertook a systematic review of the literature using Medline, PubMed and Web of Science, data provided by the Scientific Registry of Transplant Recipients and the bibliographies of key reviews. We determined a list of key questions and convened a two-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated recommendations and/or directions for future research.ResultsOf the 30 questions considered, we found inadequate evidence for the majority of questions and our recommendations were mainly based on expert opinion. There was insufficient evidence to grade three questions, but we were able to develop a consensus definition for acute kidney injury in patients with cirrhosis and provide consensus recommendations for future investigations to address key areas of uncertainty.ConclusionsDespite a paucity of sufficiently powered prospectively randomized trials, we were able to establish an evidence-based appraisal of this field and develop a set of consensus recommendations to standardize care and direct further research for patients with cirrhosis and renal dysfunction.

Features of Hemodialysis in Cirrhotic Patients:Single Center Experience

“…It has been suggested that continuous RRT may be the preferable modality in patients who are hemodynamically unstable and carry the risk of increased intracranial pressure (12). There was very high rate of ultrafiltration in some sessions of ICU patients (e.g.…”

An Update on Hepatorenal Syndrome

“…Renal replacement therapy (RRT) has been shown to improve short-term survival in patients with AKI and may provide a bridge to liver transplantation for patients with HRS who are unresponsive to vasopressors and ineligible for TIPS (22). However, in the absence of an acute reversible component to the AKI or a plan for liver transplantation, initiation and/or continuation of RRT should be evaluated carefully, as these patients have a poor prognosis and are unlikely to recover with RRT alone (22).…”

“…However, in the absence of an acute reversible component to the AKI or a plan for liver transplantation, initiation and/or continuation of RRT should be evaluated carefully, as these patients have a poor prognosis and are unlikely to recover with RRT alone (22). Molecular absorbent recirculating system (MARS) removes albumin-bound and water-soluble substances, including NO and TNF, which are involved in pathogenesis of HRS.…”

AKI in a Patient with Cirrhosis and Ascites

“…The question arose as to whether she developed HRS, a specific pathophysiologic disorder, or simply had AKI caused by the combination of hypovolemia, hypotension, and perhaps, sepsis in the setting of underlying cirrhotic liver disease (24). Although nephrologists tend to view a very low urine sodium concentration as a cardinal feature of type 1 HRS, urine sodium was initially included only as a minor criteria for diagnosis of HRS, and then, it was subsequently removed entirely as a diagnostic feature (4,8,10,21).…”