Molecular adsorbent recirculating system is ineffective in the management of type 1 hepatorenal syndrome in patients with cirrhosis with ascites who have failed vasoconstrictor treatment

Wong, Florence; Raina, Nilima; Richardson, Robert

doi:10.1136/gut.2008.174615

Cited by 85 publications

(41 citation statements)

References 54 publications

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“…However, no large-scale trial has been carried out and more recent studies (6 patients) in patients with type I HRS not responding to vasoconstrictor therapy found no improvement following MARS therapy in terms of systemic hemodynamics. They and others concluded that this therapy may only be effective as a bridge to transplant [31,32]. Prometheus employs fractional plasma separation, and adsorption with hemodialysis could be utilized to treat liver failure patients who have a need for RRT; however, it has not yet been studied in this group of patients.…”

Section: Introductionmentioning

confidence: 99%

The Challenges of Providing Renal Replacement Therapy in Decompensated Liver Cirrhosis

Gonwa¹,

Wadei²

2012

Blood Purif

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Development of renal failure requiring renal replacement therapy (RRT) in the cirrhotic patient is a devastating complication. Survival without RRT is less than 10% on average at 6 months. However, it is now appreciated that all renal failure in this group of patients is not due solely to hepatorenal syndrome, and the cause of the renal failure affects the prognosis. This paper reviews the prognosis depending on cause and points out the difficulty in making the correct diagnosis. Provision of RRT is difficult in this group of patients due to hypotension and coagulopathy which is highly prevalent. Survival with RRT is still poor with only 30–60% of patients surviving to liver transplant. Provision of RRT should be offered as a bridge to patients awaiting liver transplant or those undergoing liver transplant evaluation. Provision of long-term RRT is usually not indicated in other cirrhotic patients who develop a need for RRT except as a trial to see if renal function will return. The decision between intermittent hemodialysis or continuous renal replacement therapy (CRRT) is usually based on the clinical characteristics of the patient. Neither has been demonstrated to be superior to the other, although CRRT may be better tolerated in the unstable patient. CRRT is clearly indicated in cases of fulminant hepatic failure as it does not raise intracranial pressure. Provision of intraoperative CRRT during liver transplant may be indicated to help control volume and electrolytes in those patients presenting for liver transplant with renal failure. Newer extracorporeal support systems, such as extracorporeal albumin dialysis (MARS) and fractional plasma separation and adsorption with hemodialysis (Prometheus), have recently been developed to provide both renal and liver support in this group of patients. These are still considered experimental, although the MARS system has been utilized to treat patients with hepatorenal syndrome, and is available outside the United States.

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Section: Introductionmentioning

confidence: 99%

The Challenges of Providing Renal Replacement Therapy in Decompensated Liver Cirrhosis

Gonwa¹,

Wadei²

2012

Blood Purif

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“…Artificial liver support therapies have been evaluated for the treatment of HRS; including molecular adsorbent recirculating system (MARS), Prometheus, single pass albumin dialysis (SPAD), and single pass albumin extended dialysis (SPAED) [33][34][35][36][37]. These extracorporeal systems provide combined hepatic and renal support by removing water-soluble and albumin-bound toxins resulting in improved serum bilirubin, creatinine, and other laboratory measurements.…”

Section: Norepinephrine Versus Terlipressinmentioning

confidence: 99%

“…These extracorporeal systems provide combined hepatic and renal support by removing water-soluble and albumin-bound toxins resulting in improved serum bilirubin, creatinine, and other laboratory measurements. Unfortunately, these artificial support systems do not provide sustained responses in kidney function after discontinuation and laboratory values commonly return to pretreatment levels after discontinuation [33]. In addition to the inability to produce meaningful outcomes, other challenges to artificial liver support systems include hypotension, blood loss each time the circuit is replaced, and the frequent need for anticoagulant administration into the extracorporeal circuit to prevent clotting of the circuit.…”

Section: Norepinephrine Versus Terlipressinmentioning

confidence: 99%

Hepatorenal Syndrome

Kiser¹

2014

IJCM

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Hepatorenal syndrome (HRS) is the most serious hepatorenal disorder and one of the most difficult to treat. To date, the best treatment options are those that reverse the mechanisms underlying HRS: portal hypertension, splanchnic vasodilation, and/or renal vasoconstriction. Therefore, liver transplantation is the preferred definitive treatment option. The role of other therapies is predominantly to prolong survival sufficiently to allow patients to undergo transplantation. Terlipressin with the addition of adjunctive albumin volume expansion is the preferred pharmacologic therapy for the treatment of patients with HRS. Norepinephrine and vasopressin are acceptable alternatives in countries where terlipressin is not yet available. For patients with Type II HRS, midodrine plus octreotide appears to be an effective pharmacologic regimen that can be administered outside of an intensive care unit setting. Regardless of chosen vasoconstrictor therapy, careful monitoring is needed to ensure tissue ischemia and severe adverse effects do not occur. Artificial hepatic support devices, renal replacement therapy, and transjugular intrahepatic portosystemic shunt (TIPS) are non-pharmacologic options for patients with HRS. However, hepatic support devices and renal replacement therapies have not yet demonstrated improved outcomes and TIPS is difficult to be employed in patients with Type I HRS due to contraindications in the majority of patients. Despite advances in our understanding of hepatorenal syndrome, the disease is still associated with significant morbidity, mortality, and costs. More evidence is urgently needed to help improve patient outcomes in this difficult-to-treat population.

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“…In a randomized study, Mitzner et al [83] showed that MARS was superior to CRRT in type 1 HRS patients in terms of patient survival, improved clinical and biochemical parameters were also found. A more recent study demonstrated that MARS was ineffective in improving systemic haemodynamics in six patients with type 1 HRS who failed vasoconstrictor treatment; only transient reduction in serum creatinine occurred [84]. Another study on 32 HRS-1 patients reported a rate of complete renal response of 28% (9/32) [85].…”

Section: Therapy Of Hrs: Dialysismentioning

confidence: 99%

Hepatorenal Syndrome and Novel Advances in its Management

Fabrizi¹,

Aghemo

Messa³

2013

Kidney Blood Press Res

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Hepatorenal syndrome is a complication of end stage liver disease. It is a unique form of functional renal failure related to kidney vasoconstriction in the absence of underlying kidney pathology. Hepatorenal syndrome is classified into 2 types: type-1 HRS shows a rapid and progressive decline in renal function with a very poor prognosis (median survival of about 2 weeks); type-2 HRS has a more stable kidney failure, with a median survival of 6 months; its main clinical manifestation is refractory ascites. The most appropriate therapy for HRS is liver transplantation but only a minority of HRS patients undergo the procedure due to the high mortality; survival among liver transplant recipients is lower in HRS than among their counterparts without HRS. A large body of evidence, based on observational studies and randomized controlled trials, has been accumulated in the last decade showing that terlipressin represents a milestone in the management of HRS. According to our meta-analysis of randomized trials comparing terlipressin vs. placebo (five trials, n=243 patients), the pooled rate of patients who reversed HRS by terlipressin was 8.09 (95% CI, 3.52; 18.59) (P<0.001). Among vasoconstrictors, terlipressin (a V1 vasopressin agonist) is the most widely used; however, noradrenaline is another good choice. Vasoconstrictor drugs alone or with albumin reduce mortality compared with no intervention or albumin (RR of mortality, 0.82; 95% Confidence Intervals, 0.70; 0.96) (P<0.01). Two series of patients with HRS recurrence after the first treatment have recently shown that long-term therapy with terlipressin and albumin is beneficial as a bridge to liver transplant. Nevertheless, recovery of renal function can be achieved in less than 50% of patients with HRS after terlipressin use and the recovery of renal function may also be partial in patients who are defined full responders. Renal replacement therapy should not be considered a first-line therapy for HRS Clinical trials are under way in order to assess efficacy and safety of novel therapeutic agents for the treatment of type-1 and type-2 HRS.

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Molecular adsorbent recirculating system is ineffective in the management of type 1 hepatorenal syndrome in patients with cirrhosis with ascites who have failed vasoconstrictor treatment

Cited by 85 publications

References 54 publications

The Challenges of Providing Renal Replacement Therapy in Decompensated Liver Cirrhosis

The Challenges of Providing Renal Replacement Therapy in Decompensated Liver Cirrhosis

Hepatorenal Syndrome

Hepatorenal Syndrome and Novel Advances in its Management

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