Hepatorenal syndrome, MELD score and liver transplantation: an evolving issue with relevant implications for clinical practice

High Mortality of Cirrhotic Patients With End-Stage Renal Disease

Ascites, hepatic encephalopathy (HE), and esophageal variceal bleeding (EVB) are 3 major complications in patients with cirrhosis. Limited data exist with which to evaluate the long-term mortality of end-stage renal disease (ESRD) in cirrhotic patients with or without complications.The National Health Insurance Database in Taiwan was used to identify patients with cirrhosis hospitalized between January 1, 2007, and December 31, 2007. The study group consisted of 1068 cirrhotic patients with ESRD, and the control group consisted of 10,680 randomly selected cirrhotic patients without baseline renal function impairment.The overall 1-year and 3-year mortality rates were 48.5% and 73.1% in the ESRD group, and 32.9% and 55.6% in the control group, respectively. After adjusting for other comorbid disorders, the cirrhotic patients with ESRD showed a statistically significant increase in 3-year mortality (hazard ratio [HR], 1.65; P < 0.001). The HR for 3-year mortality of ESRD cirrhotic patients with recurrent complications was 1.98 (P < 0.001), compared to those with no recent or past complications. The HR of ESRD for 3-year mortality was 1.48 (P < 0.001) in cirrhotic patients with ascites, 1.67 (P < 0.001) in patients with EVB, and 1.19 (P = 0.147) in patients with HE.ESRD increases the mortality rate in patients with cirrhosis. Recurrent complications can account for a 2-fold increase in the 3-year mortality of ESRD cirrhotic patients. ESRD has a smaller impact on the 3-year mortality of cirrhotic patients with HE compared to those with ascites or EVB.

[Evaluation and treatment of the critically ill cirrhotic patient]

Cirrhotic patients often develop severe complications requiring ICU admission. Grade III-IV hepatic encephalopathy, septic shock, acute-on-chronic liver failure and variceal bleeding are clinical decompensations that need a specific therapeutic approach in cirrhosis. The increased effectiveness of the treatments currently used in this setting and the spread of liver transplantation programs have substantially improved the prognosis of critically ill cirrhotic patients, which has facilitated their admission to critical care units. However, gastroenterologists and intensivists have limited knowledge of the pathogenesis, diagnosis and treatment of these complications and of the prognostic evaluation of critically ill cirrhotic patients. Cirrhotic patients present alterations in systemic and splanchnic hemodynamics, coagulation and immune dysfunction what further increase the complexity of the treatment, the risk of developing new complications and mortality in comparison with the general population. These differential characteristics have important diagnostic and therapeutic implications that must be known by general intensivists. In this context, the Catalan Society of Gastroenterology and Hepatology requested a group of experts to draft a position paper on the assessment and treatment of critically ill cirrhotic patients. This article describes the recommendations agreed upon at the consensus meetings and their main conclusions.

Hepatorenal syndrome: Update on diagnosis and treatment

Acute kidney injury (AKI) is a common complication in patients with end-stage liver disease and advanced cirrhosis regardless of the underlying cause. Hepatorenal syndrome (HRS), a functional form of kidney failure, is one of the many possible causes of AKI. HRS is potentially reversible but involves highly complex pathogenetic mechanisms and equally complex clinical and therapeutic management. Once HRS has developed, it has a very poor prognosis. This review focuses on the diagnostic approach to HRS and discusses the therapeutic protocols currently adopted in clinical practice.

Cirrhotic Multiorgan Syndrome

Patients with cirrhosis and portal hypertension are at an increased risk of the development of circulatory dysfunction that may potentially result in multiple organ failure. Apart from the liver, this may involve the heart, lungs, kidneys, the immune system, the adrenal glands, and other organ systems. As the disease progresses, the circulation becomes hyperdynamic, and signs of cardiac, pulmonary, and renal dysfunction are observed, in addition to reduced survival. Infections and an altered cardiac function known as cirrhotic cardiomyopathy may be precipitators for the development of other complications such as hepatorenal syndrome. In patients with chronic organ dysfunction, various precipitating events may induce an acute-on-chronic renal failure and acute-on-chronic liver failure that negatively affect the prognosis. Future research on the pathophysiologic mechanisms of the complications and the precipitating factors is essential to understand the basics of the treatment of these challenging conditions. The aim of the present review is to focus on the development and precipitating factors of various organ failures in patients with decompensated cirrhosis.

Treatment of type 2 hepatorenal syndrome in patients awaiting transplantation: Effects on kidney function and transplantation outcomes

There is little information on the effects of treatment with vasoconstrictors plus albumin in patients with type 2 hepatorenal syndrome (HRS), particularly those awaiting liver transplantation (LT). This study reports the effects of treatment of type 2 HRS in patients on the waiting list for LT. We included 56 patients with type 2 HRS who were awaiting LT. Out of these 56 patients, 31 were treated with terlipressin and albumin. Nineteen (61%) of these 31 patients had response to therapy, and 11 of them relapsed after treatment withdrawal. There were no differences in mortality on the waiting list between responders and nonresponders. Among the 46 (82%) patients who underwent transplantation, 15 underwent transplantation with reversal of type 2 HRS, whereas the remaining 31 underwent transplantation with type 2 HRS. There were no significant differences in serum creatinine or estimated glomerular filtration rate between the 2 cohorts of patients at 3, 6, and 12 months after transplantation. There were no significant differences regarding development of acute kidney injury, need for renal replacement therapy, frequency of chronic kidney disease 1 year after transplant, length of hospitalization, and survival. In conclusion, treatment of patients with type 2 HRS with terlipressin and albumin does not appear to have beneficial effects either in pretransplantation or in posttransplantation outcomes.

Liver Graft Allocation by Means of a New, Regionally Shared "Mixed" Model: The Experience in Lazio

INTRODUCTION

Since 2013, the regional network of transplantation centers "LAZIO TRANSPLANT" have adopted a new, mixed system for the allocation of liver grafts.

METHODS

The organs from donors aged <65 are assigned to patients with higher Model for End-stage Liver Disease (MELD) scores on a common regional waiting list, whereas those from donors aged >65 are allocated to patients with higher MELD scores on a specific local waiting list (LWL) at each center, on a rotational basis.

RESULTS

The new mixed allocation model grants a more rational allocation of the "standard" organs to the patients with the actual worst MELD score in the entire region, avoiding the possibility that a patient in relatively better clinical condition might be transplanted before a more severely ill patient on another center's waiting list. Nonstandard organs, presenting slightly increased transplant risks, are still allocated on a rotational basis among the different transplant centers, ensuring them the possibility to select, on the basis of a global clinical risk evaluation, those patients in their LWL whose MELD score would not grant any possibility to compete for the "standard" organ allocation.

CONCLUSIONS

The application of the new model had no negative impact on the overall number of transplants performed or on the global list-satisfaction percentages, but has slightly improved the cumulative mortality of the patients in the waiting list, granting to the clinically worst patients a prompt graft allocation, independent of the local center belonging.

The Treatment of Hepatorenal Syndrome

Hepatorenal syndrome (HRS) is a severe complication that often occurs in patients with cirrhosis and ascites. HRS is a functional renal failure that develops mainly as a consequence of a severe cardiovascular dysfunction which is characterized by an extreme splanchnic arterial vasodilation and a reduction of cardiac output. HRS may develop in two clinical types: as an acute and rapidly progressive renal failure (AKI-HRS) or as chronic and not progressive renal failure (CKD-HRS). Several small studies and some randomized control studies have been published on the use of terlipressin plus albumin in the treatment of HRS, mainly on AKI-HRS. Terlipressin plus albumin was shown to improve renal function in almost 35-45% of patients with AKI-HRS, as well as to improve short-term survival in these patients. Terlipressin was most commonly used by intravenous boluses moving from an initial dose of 0.5-1 mg every 4 h to 3 mg every 4 h in the case of a nonresponse. In other studies, terlipressin was also given by continuous intravenous infusion. Thus, the best way to administer terlipressin in the treatment of HRS has not yet been defined. α-Adrenergic drugs, such as intravenous norepinephrine or oral midodrine plus subcutaneous octreotide, administered with albumin have also been used in the treatment of AKI-HRS, with promising results. However, we need further studies in order to define whether they can represent a real therapeutic alternative. In conclusion, available data are sufficient to state that the use of terlipressin plus albumin has really changed the management of HRS. Nevertheless, some crucial unsolved issues still exist, in particular: (a) how to predict nonresponse to treatment, (b) how to manage nonresponse to treatment and (c) how to consider the response in those patients who are candidates for liver transplant in the priority allocation process.

Hepatorenal syndrome: aetiology, diagnosis, and treatment

Acute renal impairment is common in patients with chronic liver disease, occurring in approximately 19% of hospitalised patients with cirrhosis. A variety of types of renal impairment are recognised. The most important of these is the hepatorenal syndrome, a functional renal impairment due to circulatory and neurohormonal abnormalities that underpin cirrhosis. It is one of the most severe complications of cirrhosis with survival often measured in weeks to months. A variety of treatment options exist with early diagnosis and appropriate treatment providing the best hope for cure. This paper provides a comprehensive and up-to-date review of hepatorenal syndrome and lays out the topic according to the following sections: pathophysiology, historical developments, diagnostic criteria and limitations, epidemiology, precipitating factors, predictors, clinical and laboratory findings, prognosis, treatment options, prophylaxis, and conclusion.

Extrahepatic complications to cirrhosis and portal hypertension: Haemodynamic and homeostatic aspects

In addition to complications relating to the liver, patients with cirrhosis and portal hypertension develop extrahepatic functional disturbances of multiple organ systems. This can be considered a multiple organ failure that involves the heart, lungs, kidneys, the immune systems, and other organ systems. Progressive fibrosis of the liver and subsequent metabolic impairment leads to a systemic and splanchnic arteriolar vasodilatation. This affects both the haemodynamic and functional homeostasis of many organs and largely determines the course of the disease. With the progression of the disease, the circulation becomes hyperdynamic with cardiac, pulmonary as well as renal consequences for dysfunction and reduced survival. Infections and a changed cardiac function known as cirrhotic cardiomyopathy may be involved in further aggravation of other complications such as renal failure precipitating the hepatorenal syndrome. Patients with end-stage liver disease and related complications as for example the hepatopulmonary syndrome can only radically be treated by liver transplantation. As a bridge to this treatment, knowledge on the mechanisms of the pathophysiology of complications is essential for the choice of vasoactive drugs, antibiotics, drugs with specific effects on fibrogenesis and inflammation, and drugs that target specific receptors.

Value and limitations of the BAR-score for donor allocation in liver transplantation

PURPOSE

The MELD-score was shown to be able to predict 90-day mortality in most patients with end-stage liver disease prior to liver transplantation and is used as a widely accepted measure for transplantation urgency. Prognostic ability of the BAR-score to predict 90-day post-transplant mortality by detection of unfavourable pretransplant combinations of donor and recipient factors may help to better balance urgency versus utility.

METHODS

Two German cohorts (Hannover, n=453; Kiel, n=234) were retrospectively analyzed using ROC-curve analysis, goodness-of-model-fit tests, summary measures and risk-adjusted multivariate binary regression. Included were all consecutive liver transplants performed in adult recipients (minimum age 18 years). Excluded were all combined transplants and living-related organ donor transplants.

RESULTS

Risk-adjusted multivariate regression revealed that the BAR-score is an independent risk factor for 90-day mortality after transplantation in both cohorts from Hannover and Kiel combined (p<0.001, OR=1.017, 95% CI:1.031-1.113). The area under the ROC-curve (AUROC) for the prediction of 90-day mortality using the BAR-score was 0.662 (95% CI 0.624-0.699, power>95%). Measures for association between observed 90-day mortality and the predicted probabilities in the combined cohort were concordant in 63.5% with low summary measures (Somers' D test 0.32, Goodman-Kruskal Gamma test 0.34 and Kendall's Tau a test 0.07).

CONCLUSIONS

The BAR-score performed below accepted thresholds for potentially useful clinical prognostic models. Prognostic models with better predictive ability with AUROCs>0.700, concordance>70% and larger summary measures are required for the prediction of 90-day post-transplant mortality to enable donor organ allocation with reliable weighing of urgency versus utility.

Terlipressin versus norepinephrine in the treatment of hepatorenal syndrome: a systematic review and meta-analysis

Background

Hepatorenal syndrome (HRS) is a severe and progressive functional renal failure occurring in patients with cirrhosis and ascites. Terlipressin is recognized as an effective treatment of HRS, but it is expensive and not widely available. Norepinephrine could be an effective alternative. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of norepinephrine compared to terlipressin in the management of HRS.

Methods

We searched the Medline, Embase, Scopus, CENTRAL, Lilacs and Scielo databases for randomized trials of norepinephrine and terlipressin in the treatment of HRS up to January 2014. Two reviewers collected data and assessed the outcomes and risk of bias. The primary outcome was the reversal of HRS. Secondary outcomes were mortality, recurrence of HRS and adverse events.

Results

Four studies comprising 154 patients were included. All trials were considered to be at overall high risk of bias. There was no difference in the reversal of HRS (RR = 0.97, 95% CI = 0.76 to 1.23), mortality at 30 days (RR = 0.89, 95% CI = 0.68 to 1.17) and recurrence of HRS (RR = 0.72; 95% CI = 0.36 to 1.45) between norepinephrine and terlipressin. Adverse events were less common with norepinephrine (RR = 0.36, 95% CI = 0.15 to 0.83).

Conclusions

Norepinephrine seems to be an attractive alternative to terlipressin in the treatment of HRS and is associated with less adverse events. However, these findings are based on data extracted from only four small studies.

Kidney injury in cirrhosis: pathophysiological and therapeutic aspects of hepatorenal syndromes

Acute kidney injury (AKI) is frequent in patients with cirrhosis. AKI and hyponatraemia are major determinants of the poor prognosis in advanced cirrhosis. The hepatorenal syndrome (HRS) denotes a functional and potential reversible impairment of renal function. Type 1 HRS, a special type of AKI, is a rapidly progressive AKI, whereas the renal function in type 2 HRS decreases more slowly. HRS is precipitated by factors such as sepsis that aggravate the effective hypovolaemia in decompensated cirrhosis, by lowering arterial pressure and cardiac output and enhanced sympathetic nervous activity. Therefore, attempts to prevent and treat HRS should seek to improve liver function and to ameliorate arterial hypotension, central hypovolaemia and cardiac output, and to reduce renal vasoconstriction. Ample treatment of HRS is important to prevent further progression and death, but as medical treatment only modestly improves long-term survival, these patients should always be considered for liver transplantation. Hyponatraemia, defined as serum sodium <130 mmol/L, is common in patients with decompensated cirrhosis. From a pathophysiological point of view, hyponatraemia is related to an impairment of renal solute-free water excretion most likely caused by an increased vasopressin secretion. Patients with cirrhosis mainly develop hypervolaemic hyponatraemia. Current evidence does not support routine use of vaptans in the management of hyponatraemia in cirrhosis.

Renal dysfunction in patients with cirrhosis: Where do we stand?

Patients with cirrhosis and renal failure are high-risk patients who can hardly be grouped to form precise instructions for diagnosis and treatment. When it comes to evaluate renal function in patients with cirrhosis, determination of acute kidney injury (AKI), chronic kidney disease (CKD) or AKI on CKD should be made. First it should be excluded the prerenal causes of AKI. All cirrhotic patients should undergo renal ultrasound for measurement of renal resistive index in every stage of liver dysfunction and urine microscopy for differentiation of all causes of AKI. If there is history of dehydration on the ground of normal renal ultrasound and urine microscopy the diuretics should be withdrawn and plasma volume expansion should be tried with albumin. If the patient does not respond, the correct diagnosis is HRS. In case there is recent use of nephrotoxic agents or contrast media and examination shows shock, granular cast in urinary sediment and proteinuria above 0.5 g daily, acute tubular necrosis is the prominent diagnosis. Renal biopsy should be performed when glomerular filtration rate is between 30-60 mL/min and there are signs of parenchymal renal disease. The acute renal function is preferable to be assessed with modified AKIN. Patients with AKIN stage 1 and serum creatinine ≥ 1.5 mg/dL should be at close surveillance. Management options include hemodynamic monitoring and management of fluid balance and infections, potentially driving to HRS. Terlipressin is the treatment of choice in case of established HRS, administered until there are signs of improvement, but not more than two weeks. Midodrine is the alternative for therapy continuation or when terlipressin is unavailable. Norepinephrine has shown similar effect with terlipressin in patients being in Intensive Care Unit, but with much lower cost than that of terlipressin. If the patient meets the requirements for transplantation, dialysis and transjugular intrahepatic portosystemic shunt are the bridging therapies to keep the transplant candidate in the best clinical status. The present review clarifies the latest therapeutic modalities and the proposed recommendations and algorithms in order to be applied in clinical practice.

Overview of the indications and contraindications for liver transplantation

Liver transplantation is the only definitive treatment option for patients with irrevocable acute or chronic liver failure. In the last four decades, liver transplantation has developed from an experimental approach with a very high mortality to an almost routine procedure with good short- and long-term survival rates. Here, we present an up-to-date overview of the indications and contraindications for liver transplantation. It is shown how the evaluation of a candidate and finally listing for transplantation has to be performed in a multidisciplinary setting. Meticulous listing, timing, and organ allocation are the crucial factors to achieve an optimal outcome for the individual patient on the one hand, and reasonably using the limited deceased donor pool on the other hand. Living-donor liver transplantation is demanding but necessarily increasing. Because patients after liver transplantation need lifelong aftercare, it is important for primary care clinicians to understand the basic medical problems and risks.

Liver dialysis in acute-on-chronic liver failure: current and future perspectives

Patients with acute-on-chronic liver failure (ACLF) are known to have a very high mortality rate as the majority of these patients succumb to multiorgan failure. Liver transplant remains the only option for these patients; however, there are problems with its availability, cost and also the complications and side effects associated with immunosuppression. Unlike advanced decompensated liver disease, there is a potential for hepatic regeneration and recovery in patients with ACLF. A liver support system, cell or non-cell based, logically is likely to provide temporary functional support until the donor liver becomes available or the failing liver survives the onslaught of the acute insult and spontaneously regenerates. Understanding the pathogenesis of liver failure and regeneration is essential to define the needs for a support system. Removal of hepatotoxic metabolites and inhibitors of hepatic regeneration by liver dialysis, a non-cell-based hepatic support, could help to provide a suitable microenvironment and support the failing liver. The current systems, i.e., MARS and Prometheus, have failed to show survival benefits in patients with ACLF based on which newer devices with improved functionality are currently under development. However, larger randomized trials are needed to prove whether these devices can enable restoration of the complex dysregulated immune system and impact organ failure and mortality in these patients.

Type-1 hepatorenal syndrome associated with infections in cirrhosis: natural history, outcome of kidney function, and survival

Type-1 hepatorenal syndrome (HRS) is a common complication of bacterial infections in cirrhosis, but its natural history remains undefined. To assess the outcome of kidney function and survival of patients with type-1 HRS associated with infections, 70 patients diagnosed during a 6-year period were evaluated prospectively. Main outcomes were no reversibility of type-1 HRS during treatment of the infection and 3-month survival. Forty-seven (67%) of the 70 patients had no reversibility of type-1 HRS during treatment of the infection. [Correction to previous sentence added March 10, 2014, after first online publication: "Twenty-three (33%)" was changed to "Forty-seven (67%)."] The main predictive factor of no reversibility of type-1 HRS was absence of infection resolution (no reversibility: 96% versus 48% in patients without and with resolution of the infection; P < 0.001). Independent predictive factors of no reversibility of type-1 HRS were age, high baseline serum bilirubin, nosocomial infection, and reduction in serum creatinine <0.3 mg/dL at day 3 of antibiotic treatment. No reversibility was also associated with severity of circulatory dysfunction, as indicated by more marked activity of the vasoconstrictor systems. In the whole series, 3-month probability of survival was only 21%. Factors associated with poor prognosis were baseline serum bilirubin, no reversibility of type-1 HRS, lack of resolution of the infection, and development of septic shock after diagnosis of type-1 HRS.

CONCLUSION

Type-1 HRS associated with infections is not reversible in two-thirds of patients with treatment of infection only. No reversibility of type-1 HRS is associated with lack of resolution of the infection, age, high bilirubin, and no early improvement of kidney function and implies a poor prognosis. These results may help advance the management of patients with type-1 HRS associated with infections.

Re-evaluation of the predictive score for 6-month graft survival in living donor liver transplantation in the modern era

The limitations of donor age, graft size, and the Model for End-Stage Liver Disease (MELD) score have not been apparent in living donor liver transplantation (LDLT). Our team developed a formula for predicting graft survival after LDLT; the formula includes the graft weight, donor age, MELD score, and portosystemic shunt status. The aims of this study were to re-evaluate the reliability of our formula and to assess whether our modified treatment strategy has improved 6-month graft survival. Two hundred seventeen patients were allocated into 2 groups: patients with predictive scores ≥ 1.30 (n = 162) and patients with predictive scores < 1.30 (n = 55). The latter group was also divided into subgroups of patients with scores of 1.15 to 1.30 (n = 37) and patients with scores < 1.15 (n = 18). Survival rates for patients with scores < 1.30 were significantly worse than rates for patients with scores ≥ 1.30 (P = 0.006). Survival rates for patients with scores < 1.15 were significantly worse than rates for patients with scores of 1.15 to <1.30 (P < 0.001). A multivariate analysis showed that a predictive score < 1.15 (odds ratio = 7.87, P = 0.006) and a body mass index ≥ 30 kg/m(2) (odds ratio = 13.3, P < 0.001) were independent risk factors for 6-month graft mortality. In conclusion, predictive scores reliably predict 6-month graft survival and could allow a widening of the safe ranges for donor ages and graft sizes.

Clinical course and prognostic factors of hepatorenal syndrome: A retrospective single-center cohort study

AIM

To investigate clinical and biochemical features of hepatorenal syndrome (HRS), to assess short and long-term survival evaluating potential predictors of early mortality.

METHODS

Sixty-two patients with liver cirrhosis and renal failure, defined as a serum creatinine value > 1.5 mg/dL on at least two measurements within 48 h, admitted to our tertiary referral Unit from 2001 to 201, were retrospectively reviewed. Among them, 33 patients (53.2%) fulfilled the revised criteria of the International Ascites Club for the diagnosis of HRS. Twenty-eight patients were treated with combinations of terlipressin and albumin, two with dopamine and albumin, and three with albumin alone. No patients were suitable for liver transplantation. Complete response was defined as normalization of creatinine levels to less than 1.5 mg/dL, partial response as a decrease of at least 50% but not to less than 1.5 mg/dL, no response as no reduction in creatinine or a decrease of less 50% compared to pre-treatment values. All of the patients were followed up for at least 1 year until January 2013.

RESULTS

HRS type 1 was diagnosed in 15 patients (45.5%). Hepatitis C virus infection was the primary etiology (69.6%), followed by alcohol (15.2%), and cryptogenesis (15.2%). Complete response to therapy was obtained in only 3 cases (9.1%) and partial response in 7 patients (21.2%). Median survival was 30 d (range: 10-274) without significant differences between type 1 and type 2 HRS. By univariate analysis, Child-Pugh class C (P = 0.009), presence of hepatocellular carcinoma (P = 0.04), low serum sodium (P = 0.02), high bilirubin values (P = 0.009) and high Model for End-stage Liver Disease (MELD) score (P = 0.03) were predictive factors of 30-d mortality. By multivariate analysis, only serum sodium < 132 mEq/L (OR = 31.39; P = 0.02) and MELD score > 27 (OR = 18.72; P = 0.01) were independently associated with a survival of less than one month.

CONCLUSION

HRS still has a poor prognosis, even when vasoactive drug therapies are extensively used.

Chronic kidney disease after liver transplantation: pretransplantation risk factors and predictors during follow-up

BACKGROUND

Chronic renal impairment is an emerging problem in the management of patients after liver transplantation (LT).

METHODS

We prospectively analyzed predictors of chronic kidney disease (CKD) after LT in 179 patients followed for a median of 63 months. Diagnosis of CKD was based on an estimated glomerular filtration rate (GFR) of less than 60 mL/min according to the current position statement from the Kidney Disease Improving Global Outcome. Pretransplantation risk factors were evaluated. A Cox regression analysis, with time-dependent variables evaluated during follow-up, was applied to realize a prognostic model for CKD, and a prognostic index was also calculated. The validity of the model was tested in 149 independent LT patients with a median follow-up of 46 months.

RESULTS

The cumulative incidence of CKD was 45% at 5 years after LT. Estimated GFR at LT was the only pretransplantation independent risk factor (beta, 0.33; standard error (beta), 0.07; 95% confidence interval, 0.95-0.98). Development of arterial hypertension (hazards ratio [HR], 1.83), episodes of severe infection (HR, 2.15), and estimated GFR (HR, 0.89) after LT were identified as independent prognostic factors at the Cox regression time-dependent analysis. The model was able to identify the patients at higher risk for the development of CKD in the validation set.

CONCLUSIONS

Lower renal function at transplantation is associated with a higher risk of CKD after transplantation. A predictive model based on the variation of posttransplantation variables during the course of follow-up can help the clinicians to estimate the probability of CKD in the next 12 months.

Results of pretransplant treatment of hepatorenal syndrome with terlipressin

PURPOSE OF REVIEW

Hepatorenal syndrome (HRS) is a dreaded complication of end-stage liver disease. The best treatment option for HRS is liver transplantation (LT) in suitable candidates. Pretransplant care of HRS is of utmost importance in order to secure a good posttransplant outcome. We review the advances during the last year in the diagnosis and management of HRS in candidates who are awaiting liver transplantation.

RECENT FINDINGS

New attempts at defining renal failure in cirrhosis using the Acute Kidney Injury (AKI) definition have been proposed, as this definition has the potential advantage of detecting earlier phases of kidney dysfunction. Patients who undergo liver transplantation with acute tubular necrosis recover renal function more slowly than those with HRS and have a higher incidence of chronic kidney disease at all time points after liver transplantation. Vasoconstrictor drugs, particularly terlipressin, are effective for the management of HRS; however, noradrenaline is a good choice if terlipressin is not available. Long-term treatment of HRS with vasoconstrictors until liver transplantation in those patients with HRS recurrence after the first treatment is beneficial as a bridge to liver transplantation. Data from the cohorts of patients treated with vasoconstrictors (terlipressin and midodrine) indicate that liver transplantation offers a clear survival benefit to patients with HRS regardless of prior therapy with these drugs.

SUMMARY

Ongoing advances in the management of patients with HRS before liver transplantation indicate that vasoconstrictors plus albumin should be offered to all suitable candidates. Liver transplantation remains the best treatment option for HRS.