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

Abstract

There is little information on the effects of treatment with vasoconstrictors plus albumin in patients with type 2 hepatorenal syndrome (HRS), particularly those awaiting liver transplantation (LT). This study reports the effects of treatment of type 2 HRS in patients on the waiting list for LT. We included 56 patients with type 2 HRS who were awaiting LT. Out of these 56 patients, 31 were treated with terlipressin and albumin. Nineteen (61%) of these 31 patients had response to therapy, and 11 of them relapsed after treatment withdrawal. There were no differences in mortality on the waiting list between responders and nonresponders. Among the 46 (82%) patients who underwent transplantation, 15 underwent transplantation with reversal of type 2 HRS, whereas the remaining 31 underwent transplantation with type 2 HRS. There were no significant differences in serum creatinine or estimated glomerular filtration rate between the 2 cohorts of patients at 3, 6, and 12 months after transplantation. There were no significant differences regarding development of acute kidney injury, need for renal replacement therapy, frequency of chronic kidney disease 1 year after transplant, length of hospitalization, and survival. In conclusion, treatment of patients with type 2 HRS with terlipressin and albumin does not appear to have beneficial effects either in pretransplantation or in posttransplantation outcomes.

Is type 2 hepatorenal syndrome still a potential indication for treatment with terlipressin and albumin?

“…This fact is even more pertinent taking into account that the eGFR overestimated GFR in patients with cirrhosis even when sCr was < 1.5 mg/dL. 13 We agree with Rodriguez et al 8 that the small advantage in terms of eGFR in the group of responders versus the group including nonresponders and untreated patients could have been masked by the rapid improvement of kidney function that occurs within the first few days after LT in the latter group. Nevertheless, we think that, thereafter, any residual difference in eGFR had to be annulled by the negative impact on renal function of postoperative factors.…”

“…In this issue of Liver Transplantation, Rodriguez et al 8 reports the effects of treatment of type 2 HRS in LT candidates. The most notable finding was that an increase in glomerular filtration rate (GFR) in patients who had type 2 HRS before LT did not offer any significant advantage after LT.…”

“…The most notable finding was that an increase in glomerular filtration rate (GFR) in patients who had type 2 HRS before LT did not offer any significant advantage after LT. Importantly, there were no significant differences between patients with or without reversal of type 2 HRS before LT in relation to the development of AKI, renal replacement therapy, a change in serum creatinine (sCr) or in estimated glomerular filtration rate (eGFR) over time, or to the development of CKD by 1 year after LT. 8 Before we discuss the potential reasons for this therapeutic failure, it should be pointed out that this retrospective study was performed at a single, very valuable center in Spain. This observation is important because, as highlighted by Rodriguez et al 8 in the discussion, the study was performed under 2 conditions that reduced the time to LT for patients with type 2 HRS, namely, (1) a very high rate of organ donation and (2) as of 2007, a priority allocation system in the waiting list that used the maximum value of sCr reached in Model for End-Stage Liver Disease (MELD) score updates for patients with HRS, which was to avoid a reduction of MELD after HRS reversal.…”

“…Importantly, there were no significant differences between patients with or without reversal of type 2 HRS before LT in relation to the development of AKI, renal replacement therapy, a change in serum creatinine (sCr) or in estimated glomerular filtration rate (eGFR) over time, or to the development of CKD by 1 year after LT. 8 Before we discuss the potential reasons for this therapeutic failure, it should be pointed out that this retrospective study was performed at a single, very valuable center in Spain. This observation is important because, as highlighted by Rodriguez et al 8 in the discussion, the study was performed under 2 conditions that reduced the time to LT for patients with type 2 HRS, namely, (1) a very high rate of organ donation and (2) as of 2007, a priority allocation system in the waiting list that used the maximum value of sCr reached in Model for End-Stage Liver Disease (MELD) score updates for patients with HRS, which was to avoid a reduction of MELD after HRS reversal. By reducing the waiting time for LT in patients with type 2 HRS regardless of whether they were treated or how they responded, this could have masked any Abbreviations: AKI, acute kidney injury; ATN, acute tubular necrosis; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; GFR, glomerular filtration rate; HRS, hepatorenal syndrome; LT, liver transplantation; MELD, Model for End-Stage Liver Disease; sCr, serum creatinine.…”

“…At 5 years, the prevalence of chronic kidney disease (CKD; stage 4 or 5) was significantly higher in the ATN group compared to the HRS group (56% versus 16%; P < 0.001). 6 There is little information on the effects of treatment with vasoconstrictors plus albumin in patients with HRS awaiting LT on the outcomes after LT, either in terms of survival or renal outcomes.In this issue of Liver Transplantation, Rodriguez et al 8 reports the effects of treatment of type 2 HRS in LT candidates. The most notable finding was that an increase in glomerular filtration rate (GFR) in patients who had type 2 HRS before LT did not offer any significant advantage after LT.…”