Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis

Abstract

Hepatorenal syndrome (HRS) is a serious complication of end-stage liver disease, occurring mainly in patients with advanced cirrhosis and ascites, who have marked circulatory dysfunction,1 as well as in patients with acute liver failure.2 In spite of its functional nature, HRS is associated with a poor prognosis,3 4 and the only effective treatment is liver transplantation. During the 56th Meeting of the American Association for the Study of Liver Diseases, the International Ascites Club held a Focused Study Group (FSG) on HRS for the purpose of reporting the results of an international workshop and to reach a consensus on a new definition, criteria for diagnosis and recommendations on HRS treatment. A similar workshop was held in Chicago in 1994 in which standardised nomenclature and diagnostic criteria for refractory ascites and HRS were established.5 The introduction of innovative treatments and improvements in our understanding of the pathogenesis of HRS during the previous decade led to an increasing need to undertake a new consensus meeting. This paper reports the scientific rationale behind the new definitions and recommendations. The international workshop included four issues debated by four panels of experts (see Acknowledgements). The issues were: (1) evidence-based HRS pathogenesis; (2) treatment of HRS using vasoconstrictors; (3) other HRS treatments using transjugular intrahepatic portosystemic stent-shunt (TIPS) and extracorporeal albumin dialysis (ECAD); and (4) new definitions and diagnostic criteria for HRS and recommendations for its treatment.

Reversal of hepatorenal syndrome type 1 with terlipressin plus albumin vs. placebo plus albumin in a pooled analysis of the OT‐0401 and REVERSE randomised clinical studies

“…In the OT‐0401 study, the diagnosis was based on the 1996 International Club of Ascites criteria 20. In the REVERSE study, the diagnosis was based on International Club of Ascites criteria, which were updated in 2007 1. The OT‐0401 study comprised patients with chronic liver disease or acute (de novo onset within 6 weeks) viral and/or alcoholic hepatitis, and the REVERSE study comprised patients with cirrhosis and ascites, with or without superimposed alcoholic hepatitis.…”

“…Hepatorenal syndrome type 1 (HRS‐1) is a rapidly progressive but potentially reversible form of renal failure that may develop in patients with cirrhosis and ascites, acute liver failure, or alcoholic hepatitis 1. In patients with HRS‐1, serum creatinine (SCr) increases to >226 μmol/L within 2 weeks, frequently after a precipitating event, such as an infection or gastrointestinal bleeding 1, 2.…”

“…In patients with HRS‐1, serum creatinine (SCr) increases to >226 μmol/L within 2 weeks, frequently after a precipitating event, such as an infection or gastrointestinal bleeding 1, 2. Renal failure develops subsequent to a series of pathophysiologic haemodynamic changes.…”

Fifteen years’ experience with transjugular intrahepatic portosystemic shunt (TIPS) using bare stents: retrospective review of clinical and technical aspects

“…Indicazioni più rare ed oggetto di studi non controllati condotti su piccoli gruppi di pazienti, alcune delle quali non uniformemente accettate sono: la trombosi portale, la sindrome di Budd-Chiari, l'ascite pleurica [8][9][10], la sindrome epato-polmonare (HPS) [11], la sindrome epato-renale (HRS) [3,[12][13][14][15][16][17], la profilassi del sanguinamento intraoperatorio in pazienti cirrotici con ipertensione portale candidati ad interventi di chirurgia addominale maggiore [8,18,19] e la tutela della pervietà portale pre-trapianto epatico (OLT) [20,21].…”

“…Less common indications, some of which are not universally accepted, have been investigated by uncontrolled studies conducted on small patient series. These include portal thrombosis, Budd-Chiari syndrome, pleural ascites [8][9][10], hepatopulmonary syndrome (HPS) [11], hepatorenal syndrome (HRS) [3,[12][13][14][15][16][17], prophylaxis of intraoperative bleeding in cirrhotic patients with portal hypertension who are candidates for major abdominal surgery [8,18,19] and maintenance of portal vein patency prior to orthotopic liver transplantation (OLT) [20,21].…”