Background & Aims-Hepatorenal syndrome (HRS) type 1 is a progressive functional renal failure in subjects with advanced liver disease. The aim of this study was to evaluate the efficacy and safety of terlipressin, a systemic arterial vasoconstrictor, for cirrhosis type 1 HRS.

In comparison with large-volume paracentesis, the creation of a transjugular intrahepatic portosystemic shunt can improve the chance of survival without liver transplantation in patients with refractory or recurrent ascites.

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Background and aims: Diagnosis of moderately impaired renal function is of particular importance in patients with cirrhosis of the liver. Whereas patients with a markedly impaired glomerular filtration rate can be diagnosed easily by elevated serum creatinine concentrations, moderately reduced renal function may be missed by this conventional parameter. Recently, cystatin C has been suggested as a sensitive marker of renal function, independent of sex or muscle mass. Therefore, the aim of this study was to investigate the value of serum cystatin C concentration for the detection of moderately impaired renal function. Methods: Ninety seven inhospital patients with cirrhosis and a 24 hour creatinine clearance of at least 40 ml/min were investigated and divided into group 1 (creatinine clearance >70 ml/min; n=55) and group 2 (creatinine clearance 40-69 ml/min; n=42). Results: Serum cystatin C concentrations (mean (SD): 1.31 (0.51) v 1.04 (0.34) mg/l (p=0.008)) and creatinine concentrations (1.03 (0.52) v 0.86 (0.22) mg/100 ml (p=0.03)) were higher in group 2 than in group 1; there was no significant difference in urea concentrations. Receiver-operator characteristics (ROC) revealed a differential diagnostic advantage of cystatin C over creatinine and urea. At cut off concentrations of 1.0 mg/l, 0.9 mg/100 ml, and 28 mg/100 ml, respectively, cystatin C, creatinine, and urea exhibited 69%, 45%, and 44% sensitivity (p<0.05). As patients with a small muscle mass or reduced physical activity could be particularly prone to overestimation of their renal function, separate analyses were performed for the subgroups of female and Child-Pugh class C patients, respectively. In both groups, discrimination between patients with moderately impaired and normal renal function was best with cystatin C. In female patients, sensitivity of cystatin C (77.8%) was superior (p<0.05) to that of creatinine (38.9%) and urea (41.2%). In Child-Pugh C patients, the ROC curve was significantly better for cystatin C than for creatinine. Conclusions: Serum cystatin C determination could be a valuable tool in patients with cirrhosis, particularly with Child-Pugh class C or in female patients, for early diagnosis of moderately impaired renal function.

Hepatic arterial buffer response (HABR) is considered an important compensatory mechanism to maintain perfusion of the liver by hepatic arterial vasodilation on reduction of portal venous perfusion. HABR has been suggested to be impaired in patients with advanced cirrhosis. In patients with hepatopetal portal flow, placement of a transjugular intrahepatic portosystemic shunt (TIPS) reduces portal venous liver perfusion. Accordingly, patients with severe cirrhosis should have impaired HABR after TIPS implantation. Therefore, the aim of this study was to investigate the effect of TIPS on HABR as reflected by changes in resistance index ( H epatic arterial buffer response (HABR) is an intrinsic regulatory mechanism of the liver to maintain total hepatic blood flow when portal perfusion decreases. Increased hepatic arterial blood flow mediated by adenosine washout in the portal triad 1-3 and independent of hepatic oxygen supply or demand compensates for the reduced portal tributary blood flow (for review, see Lautt 4,5 ). This phenomenon has been shown under various experimental conditions such as endotoxinemia 6 or portal vein ligation 7 and in the clinical setting after liver transplantation. 8 Just recently, maintenance of HABR has been shown in an animal model of cirrhosis (namely, CCl 4 -induced cirrhosis in the rat). 9,10 Thus far, it is not clear whether HABR is preserved in patients with cirrhosis and whether it is dependent on the stage of liver disease. Several studies have shown an increased hepatic arterial resistance in patients with cirrhosis. This was related to the degree of portal hypertension, 11,12 portal resistance, 12,13 and Child-Pugh score, 12 respectively. In contrast to these observations, Kleber et al. 14 recently reported an increased hepatic arterial flow volume and decreased pulsatility index of the hepatic artery in Child-Pugh class C patients. In this study, intra-arterial infusion of adenosine induced an increase in hepatic arterial blood flow that was independent of Child-Pugh class, suggesting that HABR may be independent of the stage of liver disease.Hepatofugal portal venous blood flow has been reported in 2% to 15% of patients with cirrhosis. [15][16][17] According to the HABR hypothesis, this condition should be a strong stimulus for hepatic arterial vasodilation. Similarly, the transjugular intrahepatic portosystemic shunt (TIPS) procedure results in a decreased portal perfusion fraction of total liver blood flow. 18 Therefore, assuming an impaired HABR in patients with advanced cirrhosis, hepatic arterial blood flow should increase less and the decrease in resistance of the hepatic artery should be lower after the TIPS procedure than in patients with compensated cirrhosis.To test this hypothesis, we compared the hepatic arterial resistance index (RI) in cirrhotic patients with hepatopetal and hepatofugal portal venous blood flow. Furthermore, the effects of TIPS on RI were examined in both groups of patients using duplex Doppler ultrasonography. Patients and MethodsPatients. A...