Pathogenesis and management of hepatorenal syndrome in patients with cirrhosis

Abstract

Hepatorenal syndrome is a severe complication of advanced liver cirrhosis, in patients with ascites and marked circulatory dysfunction. It is clearly established that it has a functional nature, and that it is related to intense renal vasoconstriction. Despite its functional origin, the prognosis is very poor. In the present review, the most recent advances in diagnosis, pathophysiology, and treatment are discussed. Recent developments in pathophysiology are the basis of the new therapeutic strategies, which are currently under evaluation in randomised clinical trials.

Systemic abnormalities in liver disease

“…One is hepatitis virus-associated nephropathy including membranous nephropathy, membranoproliferative glomerulonephritis (MPGN) and mesangioproliferative glomerulonephritis [121][122][123] . The other is hepato-renal syndrome (HRS), which is a serious complication of advanced liver cirrhosis [124] . When a patient with chronic liver disease has proteinuria and/or hematuria, hepatitis virus-associated nephropathy should be considered (Figure 1) [122] .…”

“…The clinical manifestations of renal diseases may include hematuria, nephritic range proteinuria and renal insufficiency. HCVinfected patients should be screened for proteinuria, hematuria, hypertension and renal function, as well as for cryoglobulinemia, complement and rheumatoid factors [124] . A kidney biopsy should be performed when significant proteinuria and/or impaired renal function are observed (Figure 1).…”

“…Recently, the effectiveness of anti-CD20 chimeric monoclonal antibody (rituximab) in the treatment of cryoglobulinemic glomerulonephritis has been reported [142] . HRS HRS involves renal failure in patients with severe liver disease in the absence of any identifiable renal pathology [124,143,144] . The incidence of HRS in patients with cirrhosis and ascites is 18% and 39% after 1 and 5 years of follow-up, respectively [145] .…”

Treatment of type 2 hepatorenal syndrome in patients awaiting transplantation: Effects on kidney function and transplantation outcomes

“…5 In the last decade, an effective pharmacological therapy based on the use of vasoconstrictors, particularly terlipressin (but also noradrenalin), associated with the administration of albumin has been introduced. [1][2][3][4]7 This treatment causes a marked increase in GFR in approximately 50% of patients and improves survival in type 1 HRS. [8][9][10][11][12] Therefore, this pharmacological treatment has become the standard of care for this condition.…”

QT interval prolongation: a risk factor for development of hepatorenal syndrome in cirrhotic patients with acute variceal bleeding

“…9 Acute variceal bleeding is a well-recognized precipitant for hepatorenal syndrome (HRS), especially in advanced cirrhosis. 10 Reduced cardiac contractility due to cirrhotic cardiomyopathy, along with reduced cardiac output and mean arterial pressure, predisposes to renal dysfunction and HRS. 11 Hence, whether QT interval prolongation, a well-accepted marker of cardiac dysfunction in cirrhosis, can predict the development of HRS following an episode of acute variceal bleeding remain uncertain.…”