Transplantation of cadaveric kidneys from patients with hepatorenal syndrome. Evidence for the functional nature of renal failure in advanced liver disease

1. The hepatorenal syndrome is the development of renal failure in patients with severe liver disease in the absence of any identifiable renal pathology. 2. Decreased glomerular filtration is caused by a reduction in both renal blood flow and the renal filtration fraction. These changes arise as a consequence of a fall in mean arterial pressure due to systemic vasodilatation, activation of the sympathetic nervous system causing renal vasoconstriction, and increased synthesis of several vasoactive mediators, which together modulate both renal blood flow and the glomerular capillary ultrafiltration coefficient, and thence filtration fraction. 3. Patients with liver disease developing renal failure should have hypovolaemia excluded by volume challenge, and all nephrotoxic drugs including diuretics should be stopped. Broad-spectrum antibiotics should be given for subclinical infection, which may be a treatable precipitant of renal failure in cirrhosis. Renal perfusion should be optimized by ensuring that the blood pressure and systemic haemodynamics are adequate, and that if renal venous pressure is elevated, due to tense ascites, it is alleviated. 4. The prognosis of hepatorenal syndrome is poor with a >90% mortality. However, patients can and do recover from the hepatorenal syndrome, but only if there is a significant improvement of their liver function, or if they undergo liver transplantation.

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Hepatorenal Syndrome: Diagnosis and Treatment – newsreel –

Romanian Journal of Internal Medicine ◽

10.1515/rjim-2016-0024 ◽

2016 ◽

Vol 54 (3) ◽

pp. 143-150 ◽

Cited By ~ 1

Author(s):

Aurelia Enescu ◽

F. Petrescu ◽

P. Mitruţ ◽

Ileana Octavia Petrescu ◽

V. Pădureanu ◽

...

Keyword(s):

Renal Failure ◽

Liver Cirrhosis ◽

Hepatorenal Syndrome ◽

Chronic Renal Disease ◽

Therapeutic Modalities ◽

Functional Nature ◽

Acute Renal Insufficiency ◽

Intrahepatic Portosystemic Shunt

Abstract Hepatorenal syndrome (HRS) is defined as renal failure that occurs in the presence of severe acute or chronic liver disease in the absence of underlying renal pathology. Due to the functional nature of the disease and the absence of specific diagnostic markers, HRS diagnosis is determined based on positive criteria associated with excluding other causes of renal failure in patients with liver cirrhosis and ascites. Differentiation from other types of acute or chronic renal disease is extremely difficult and therapeutic options are limited, prophylactic behavior is most appropriate in patients with severe hepatic disease and risk factors for the installation of hepatorenal syndrome. Highlighting all precipitating factors of acute renal insufficiency and therapeutic modalities in order to minimize adverse events is an important step in improving the follow-up of the patients with liver cirrhosis. The prognosis is reserved especially for type 1 HRS. Liver transplantation is the best option for patients without contraindications. The therapies introduced in recent years, such as vasoconstrictor drugs or transjugular intrahepatic portosystemic shunt are effective methods in the renal function improvement.

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The patient with hepatorenal syndrome

10.1093/med/9780199592548.003.0169_update_001 ◽

2018 ◽

Author(s):

Andrés Cárdenas ◽

Pere Ginès

Keyword(s):

Renal Failure ◽

Liver Disease ◽

Bacterial Infections ◽

Hepatorenal Syndrome ◽

Compensatory Response ◽

Renal Vasoconstriction ◽

Bacterial Peritonitis ◽

Portosystemic Shunts ◽

Line Of Therapy ◽

End Stage

Hepatorenal syndrome (HRS) is a dreaded and common complication of patients with end-stage liver disease. The syndrome is characterized by functional renal failure due to renal vasoconstriction in the absence of underlying kidney pathology. The pathogenesis of HRS is the result of an extreme underfilling of the arterial circulation secondary to an arterial vasodilation located in the splanchnic circulation. This phenomenon triggers a compensatory response with activation of vasoconstrictor systems leading to intense renal vasoconstriction.Besides HRS, there are several other causes of renal failure in patients with cirrhosis including those secondary to bacterial infections, hypovolaemia, nephrotoxicity, and intrinsic renal disease. Thus, the diagnosis of HRS is based on established diagnostic criteria aimed at excluding non-functional causes of renal failure.The prognosis of patients with HRS is poor, especially in those who have a rapidly progressive course. Liver transplantation is the best option in suitable candidates, but it is not always applicable due to the short survival expectancy of listed candidates.Pharmacological therapies based on the use of vasoconstrictor drugs to reverse splanchnic vasodilation are the standard first line of therapy. The vasopressin analogue terlipressin is the best proven. Transjugular intrahepatic portosystemic shunts may be helpful in limited circumstances. Prevention of HRS can be attained with the use of albumin infusion in patients with spontaneous bacterial peritonitis, with norfloxacin in patients very advanced liver disease and with N-acetylcysteine in those with severe acute alcoholic hepatitis.

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Continuous Arterio-Venous Ultrafiltration in Cirrhotic Patients with Ascites or Renal Failure

The International Journal of Artificial Organs ◽

10.1177/039139888600900409 ◽

1986 ◽

Vol 9 (4) ◽

pp. 253-256 ◽

Cited By ~ 10

Author(s):

Murray Epstein ◽

Guido O. Perez ◽

Luis A. Bedoya ◽

Reynaldo Molina

Keyword(s):

Renal Failure ◽

Renal Function ◽

Acute Renal Failure ◽

Liver Disease ◽

Liver Failure ◽

Pulmonary Edema ◽

Functional Impairment ◽

Advanced Liver Disease ◽

The Third ◽

Cirrhotic Patients

To asses whether continuous arteriovenous ultrafiltration (CAVU) might constitute a useful alternative to hemodialysis in the management of patients with advanced liver failure, we carried out CAVU in 3 patients with decompensated Laennec's cirrhosis. CAVU was utilized in two patients with acute renal failure and pulmonary edema to stabilize renal function and facilitate administration of large amounts of fluid. In the third case, CAVU was successfully utilized to mobilize fluid in a patient refractory to conventional diuretic regimens. We conclude that CAVU may constitute an appropriate alternative to traditional hemodialysis in patients with advanced liver disease and renal functional impairment.

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Renal failure in chronic liver disease and the hepatorenal syndrome

British Journal of Hospital Medicine ◽

10.12968/hmed.2011.72.9.497 ◽

2011 ◽

Vol 72 (9) ◽

pp. 497-503 ◽

Cited By ~ 3

Author(s):

Brijesh Srivastava ◽

Graeme JM Alexander

Keyword(s):

Renal Failure ◽

Liver Disease ◽

Chronic Liver Disease ◽

Hepatorenal Syndrome ◽

Chronic Liver

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Risk Factors and Outcome of 107 Patients with Decompensated Liver Disease and Acute Renal Failure (Including 26 Patients with Hepatorenal Syndrome): The Role of Hemodialysis

Renal Failure ◽

10.3109/08860229509026250 ◽

1995 ◽

Vol 17 (2) ◽

pp. 135-146 ◽

Cited By ~ 56

Author(s):

Frieder Keller ◽

Helmut Heinze ◽

Friederike Jochimsen ◽

JÜRgen Paszfall ◽

Detlef Schuppan ◽

...

Keyword(s):

Risk Factors ◽

Renal Failure ◽

Acute Renal Failure ◽

Liver Disease ◽

Hepatorenal Syndrome ◽

Decompensated Liver Disease

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Poor outcomes with treatment of hepatorenal syndrome type 1 with splancnic vasoconstrictors and albumin: report of seven cases and review of the literature

Arquivos de Gastroenterologia ◽

10.1590/s0004-28032009000300014 ◽

2009 ◽

Vol 46 (3) ◽

pp. 214-218 ◽

Cited By ~ 3

Author(s):

Jamile Rosário Kalil ◽

Liv Aparicio Cerqueira ◽

Daniel Silva Barbosa ◽

Marina Pamponet Motta ◽

Marília da Silva Nery ◽

...

Keyword(s):

Renal Failure ◽

Liver Disease ◽

Hepatorenal Syndrome ◽

Multiple Organ ◽

High Dose ◽

Syndrome Type ◽

Results Of Treatment ◽

Baseline Creatinine ◽

End Stage

CONTEXT: Treatment of hepatorenal syndrome type 1 (HRS-1) with splancnic vasoconstrictors and high-dose albumin has been associated with reversal of renal failure in approximately 60% to 80% of the cases in pilot or uncontrolled studies. OBJECTIVE: To evaluate the results of treatment of HRS-1 with terlipressin and high-dose albumin. METHODS: All patients with HRS-1 that underwent treatment with terlipressin and high-dose albumin at our unit were retrospectively reviewed. Outcomes including reversal of renal failure and death were recorded and compared to baseline clinical and laboratory parameters. RESULTS: Seven subjects (median age 64 [47-69] years, 5 males) with median Child-Pugh and MELD scores of 12 [10-15] and 22 [17-38], respectively, hospitalized with decompensated chronic liver disease secondary to tense ascitis and infections, who exhibited criteria for HRS-1, were submitted to therapy with terlipressin and high-dose albumin according to a predefined standard protocol. Baseline creatinine levels were 2.9 [2.3-4.0] mg/mL. None of the patients achieved reversal of HRS-1 and five subjects died on-treatment due to sudden-death (n = 1), multiple organ dysfunction associated with end-stage liver failure (n = 2) and sepsis (n = 2). CONCLUSIONS: Treatment of HRS-1 with terlipressin and high-dose albumin was not associated with reversal of renal failure, but most of the treated subjects had severe end-stage liver disease with high MELD scores as well as high baseline creatinine values, parameters previously associated with bad outcomes.

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