Hepatorenal Syndrome: A Cause of Kidney Failure in Cirrhosis
Hepatorenal Syndrome: A Cause of Kidney Failure in Cirrhosis
The most recent guidelines, published in 2010 by the European Association for the Study of the Liver (EASL), recommend terlipressin (1 mg/4–6 h as IV bolus) together with albumin as first-line treatment for patients with type 1 HRS. The aim of treatment is to decrease serum creatinine levels to<1.5 mg/dL (<133 μmol/L). Modifications of the dose are guided by changes in serum creatinine concentration; if serum creatinine level decreases by at least 25% after 3 days of treatment, the dose is maintained, and if not, the dose is increased to 2 mg/4–6 h. If there is recurrence at any time after treatment discontinuation, patients should be re-treated with terlipressin and albumin. Alternatives to terlipressin are noradrenaline and midodrine plus octreotide, both in combination with albumin, yet information about efficacy is very limited. Patients treated with vasoconstrictors should be followed up carefully throughout treatment for early detection of side effects, particularly cardiovascular events and pulmonary edema. Main contraindications to vasoconstrictor drugs are severe cardiovascular diseases. The use of TIPS is not recommended and RRT should be used only in patients not responding to vasoconstrictors who fulfill criteria for kidney support. As far as patients who are candidates for transplant is concerned, EASLguidelines recommend treatment of HRS with vasoconstrictors before liver transplant. Moreover, liver transplant alone is appropriate, with combined liver-kidney transplant reserved for only patients who have been on RRT for more than 6–8 weeks. Although the guidelines state that vasoconstrictor therapy is effective for the treatment of type 2 HRS, no specific recommendation is made to treat these patients due to limited data.
The AASLD (American Association for the Study of the Liver) guidelines published in 2009 recommend that patients with type 1 HRS be treated with midodrine and octreotide together with albumin. It should be noted that terlipressin is not available in the United States. These guidelines also emphasize that patients who are candidates for liver transplant should be referred immediately to transplant centers because of their low survival expectancy.
Management of HRS According to Guidelines of International Societies
The most recent guidelines, published in 2010 by the European Association for the Study of the Liver (EASL), recommend terlipressin (1 mg/4–6 h as IV bolus) together with albumin as first-line treatment for patients with type 1 HRS. The aim of treatment is to decrease serum creatinine levels to<1.5 mg/dL (<133 μmol/L). Modifications of the dose are guided by changes in serum creatinine concentration; if serum creatinine level decreases by at least 25% after 3 days of treatment, the dose is maintained, and if not, the dose is increased to 2 mg/4–6 h. If there is recurrence at any time after treatment discontinuation, patients should be re-treated with terlipressin and albumin. Alternatives to terlipressin are noradrenaline and midodrine plus octreotide, both in combination with albumin, yet information about efficacy is very limited. Patients treated with vasoconstrictors should be followed up carefully throughout treatment for early detection of side effects, particularly cardiovascular events and pulmonary edema. Main contraindications to vasoconstrictor drugs are severe cardiovascular diseases. The use of TIPS is not recommended and RRT should be used only in patients not responding to vasoconstrictors who fulfill criteria for kidney support. As far as patients who are candidates for transplant is concerned, EASLguidelines recommend treatment of HRS with vasoconstrictors before liver transplant. Moreover, liver transplant alone is appropriate, with combined liver-kidney transplant reserved for only patients who have been on RRT for more than 6–8 weeks. Although the guidelines state that vasoconstrictor therapy is effective for the treatment of type 2 HRS, no specific recommendation is made to treat these patients due to limited data.
The AASLD (American Association for the Study of the Liver) guidelines published in 2009 recommend that patients with type 1 HRS be treated with midodrine and octreotide together with albumin. It should be noted that terlipressin is not available in the United States. These guidelines also emphasize that patients who are candidates for liver transplant should be referred immediately to transplant centers because of their low survival expectancy.
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