Hepatorenal syndrome: a severe, but treatable, cause of kidney failure in cirrhosis

Comparison of Measured Glomerular Filtration Rate Versus Estimated Glomerular Filtration Rate in Indian Cirrhotic Patients: Report of a Pilot Study

Background

Renal impairment significantly affects morbidity and mortality rates of cirrhosis patients. Studies on glomerular filtration rate (eGFR) estimation did not include cirrhosis patients. These equations are erroneous and unreliable in cirrhosis due to sarcopenia. Further, the accuracy of eGFR equations varies across different ethnic groups. Measurement of GFR by iohexol clearance is a gold standard method of accurate determination of GFR. There is scarce data on iohexol GFR in cirrhosis and none in Indian population.

Methodology

This was prospective observational study. Consecutive adult patients with cirrhosis with stable renal function for prior 1 month were included. Iohexol weight-based dosage was given and timed blood samples were taken to measure iohexol clearance. Plasma iohexol levels was measured by high performance liquid chromatography (HPLC) and Cystatin-C was measured by ELISA in plasma samples.

Results

Thirty-five patients were enrolled in the study. Hepatitis B (n = 5), hepatitis C (n = 4); alcoholic liver disease (n = 20), metabolic dysfunctional associated steatotic liver disease (n = 2), others/overlap (n = 3). The average eGFR by MDRD4, MDRD6, CKD-EPI Creat, CKD EPI Cys C, CKD EPI Creat-Cys C, RFHand GRAIL formulae were 105.24(24.2),104.75(23.5),102.14(15.9),68.91(16.5),82.91(15.21), 67.27 (14.08) and 112.9 (19.5) ml/min ml/min/1.73m2, respectively. The average mGFR measured by iohexol method was 73.44 (16.8)ml/min/1.73 m2. 30% agreement with mGFR was found with eGFR by MDRD4 in 38.2% (n = 13), MDRD6 38.2% ((n = 13), CKD-EPI Creat in 35.2% (n = 12), CKD EPI Cys C in 79.41% (n = 27), CKD EPI Creat-Cys C in 76.42% (n = 26), RFH 76.4% (n = 26) and GRAIL 20.5% (n = 7).

Conclusion

The eGFR equations using creatinine are imprecise and less accurate in Indian patients with cirrhosis. All equations overestimate GFR. Equations especially developed for cirrhosis patients like MDRD6 are also not precise. Cystatin C based equations are better than creatinine-based equations. Further studies with large sample size are needed to establish an accurate method of GFR assessment in Indian patients with cirrhosis.

Early blood pressure drop predicts renal function deterioration and mortality in ICU patients with liver failure: a retrospective cohort study

OBJECTIVE

To investigate the association between early blood pressure drop and worsening renal function (WRF) in ICU patients with liver failure and to evaluate their clinical outcomes.

DESIGN

Retrospective observational study.

SETTING

Intensive Care Medicine.

PATIENTS

Patients admitted to the ICU for the first time during their first hospitalization; diagnosed with liver failure according to the International Classification of Diseases, Ninth and Tenth Revision codes; and aged ≥18 years were included. Patients with a peak systolic blood pressure (SBP) drop of <0 mmHg were excluded.

INTERVENTION

We analyzed data of ICU patients with liver failure from the Medical Information Mart for Intensive Care IV version 2.2 database. Descriptive statistics, analysis of variance, Kruskal-Wallis test, and chi-square test were employed for analysis. Multivariate linear regression models were used to assess the determinants of blood pressure decline. Cox proportional hazards and generalized additive models were used to evaluate MAIN VARIABLES OF INTEREST: The relationship between blood pressure decline, WRF, and 60-day in-hospital mortality were evaluated, along with subgroup analyses.

RESULTS

Peak SBP drop was independently associated with higher risks of WRF (P < 0.001) and 60-day in-hospital mortality (P < 0.001), even after adjusting for potential confounders, including baseline SBP. The independent risk relationship observed between peak diastolic blood pressure, mean arterial pressure drop, and the occurrence of WRF and 60-day in-hospital mortality was similar.

CONCLUSIONS

In ICU patients with liver failure, a significant early drop in blood pressure was associated with a higher incidence of WRF, increased risk of 60-day in-hospital mortality, and poorer prognoses.

Hepatorenal Syndrome-Novel Insights into Diagnostics and Treatment

Hepatorenal syndrome (HRS) is a disorder associated with cirrhosis and renal impairment, with portal hypertension as its major underlying cause. Moreover, HRS is the third most common cause of acute kidney injury, thus creating a major public health concern. This review summarizes the available information on the pathophysiological implications of HRS. We discuss pathogenesis associated with HRS. Mechanisms such as dysfunction of the circulatory system, bacterial infection, inflammation, impaired renal autoregulation, circulatory, and others, which have been identified as critical pathways for development of HRS, have become easier to diagnose in recent years. Additionally, relatively recently, renal dysfunction biomarkers have been found indicating renal injury, which are involved in the pathophysiology of HRS. This review also summarizes the available information on the management of HRS, focusing on vasoconstrictive drugs, renal replacement therapy, and liver transplant together with currently being investigated novel therapies. Analyzing new discoveries for the underlying causes of this condition assists the general research to improve understanding of the mechanism of pathophysiology and thus prevention of HRS.

Hepatorenal syndrome: Current concepts and future perspectives

Hepatorenal syndrome (HRS), a progressive but potentially reversible deterioration of kidney function, remains a major complication in patients with advanced cirrhosis, often leading to death before liver transplantation (LT). Recent updates in the pathophysiology, definition, and classification of HRS have led to a complete revision of the nomenclature and diagnostic criteria for HRS type 1, which was renamed HRS-acute kidney injury (AKI). HRS is characterized by severe impairment of kidney function due to increased splanchnic blood flow, activation of several vasoconstriction factors, severe vasoconstriction of the renal arteries in the absence of kidney histologic abnormalities, nitric oxide dysfunction, and systemic inflammation. Diagnosis of HRS remains a challenge because of the lack of specific diagnostic biomarkers that accurately distinguishes structural from functional AKI, and mainly involves the differential diagnosis from other forms of AKI, particularly acute tubular necrosis. The optimal treatment of HRS is LT. While awaiting LT, treatment options include vasoconstrictor drugs to counteract splanchnic arterial vasodilation and plasma volume expansion by intravenous albumin infusion. In patients with HRS unresponsive to pharmacological treatment and with conventional indications for kidney replacement therapy (KRT), such as volume overload, uremia, or electrolyte imbalances, KRT may be applied as a bridging therapy to transplantation. Other interventions, such as transjugular intrahepatic portosystemic shunt, and artificial liver support systems have a very limited role in improving outcomes in HRS. Although recently developed novel therapies have potential to improve outcomes of patients with HRS, further studies are warranted to validate the efficacy of these novel agents.

Quantitative evaluation of renal tissue changes in patients with liver cirrhosis by shear wave elastography

PURPOSE

Hepatocirrhotic nephropathy progresses rapidly and has a poor prognosis, and early detection of renal changes in patients with cirrhosis is particularly important for its prevention and treatment. The objective of this study was to evaluate the value of shear wave elastography (SWE) in the early diagnosis of hepatocirrhotic nephropathy.

METHODS

206 hepatic cirrhosis patients with normal conventional renal function were enrolled and divided into Child-Pugh grade A (Group A), Child-Pugh grade B (Group B), and Child-Pugh grade C (Group C) according to the Child-Pugh grading method. Meanwhile, 60 healthy volunteers matched in age and sex were selected as the control group. The maximum Young's modulus (Emax), average Young's modulus (Emean), and minimum Young's modulus (Emin) of the left renal parenchyma were measured by SWE in all subjects. The Emax, Emean, and Emin values of the left renal parenchyma were compared between the cirrhosis and control groups.

RESULTS

The Emax, Emean, and Emin values of left renal parenchyma in cirrhosis group were higher than those in control group (p = 0.00, 0.00, 0.00). The Emax, Emean, and Emin values of left renal parenchyma in cirrhosis group B and group C were higher than those in control group (p = 0.00, 0.00, 0.00; p = 0.00, 0.00, 0.00), but these values in cirrhosis group A were not significantly different from control group(p = 0.48, 0.52, 0.92). Comparison of the Emax, Emean, and Emin values in left renal parenchyma of three cirrhosis groups, the values of Group B and Group C were higher than those of Group A (p = 0.00, 0.00, 0.00; p = 0.00, 0.00, 0.00), and there was no significant difference between Group B and Group C (p = 0.71, 0.18, 0.39).

CONCLUSION

SWE can detect renal tissue damage in patients with liver cirrhosis earlier than changes identified during routine laboratory examination by quantitatively measuring the elastic parameters of renal parenchyma and may become a new method for early diagnosis of hepatorenal syndrome.

Hepatorenal syndrome: pathophysiology and evidence-based management update

Hepatorenal syndrome (HRS) is a functional renal failure that develops in patients with advanced hepatic cirrhosis with ascites and in those with fulminant hepatic failure. The prevalence of HRS varies among studies but in general it is the third most common cause of acute kidney injury (AKI) in cirrhotic patients after pre-renal azotemia and acute tubular necrosis. HRS carries a grim prognosis with a mortality rate approaching 90% three months after disease diagnosis. Fortunately, different strategies have been proven to be successful in preventing HRS. Although treatment options are available, they are not universally effective in restoring renal function but they might prolong survival long enough for liver transplantation, which is the ultimate treatment. Much has been learned in the last two decades regarding the pathophysiology and management of this disease which lead to notable evolution in the HRS definition and better understanding on how best to manage HRS patients. In the current review, we will summarize the recent advancement in epidemiology, pathophysiology, and management of HRS.

Cost-Utility Analysis of Vasoconstrictors Plus Albumin in the Treatment of Thai Patients with Type 1 Hepatorenal Syndrome

Purpose

Type 1 hepatorenal syndrome (type 1 HRS) or hepatorenal syndrome-acute renal injury (HRS-AKI) leads to high short-term mortality rates in patients with cirrhosis. Vasoconstrictor therapy effectively improves survival of these patients and has been a bridge to liver transplantation. The aim of this study was to assess the cost-utility of terlipressin plus albumin (T+A) and noradrenaline plus albumin (N+A) compared to best supportive care (BSC) for treating type 1 HRS patients in Thailand.

Methods

A cost-utility analysis using a six-state Markov model was performed from societal and payer perspectives over a lifetime horizon. The clinical outcomes, costs, and utility parameters were obtained from literature, network meta-analyses, and expert opinion. One-way and probabilistic sensitivity analyses were conducted to account for uncertainty.

Results

The T+A yielded the highest cost (848,325 Thai Baht (THB)) and health outcomes (2.82 life-years (LY) and 2.27 quality-adjusted life-years (QALY)). Compared to BSC, incremental cost-effectiveness ratios (ICERs) of the T+A and N+A were 377,566 and 412,979 THB per QALY gained, respectively. If N+A is administered outside the intensive care unit, the ICER was 308,964 THB per QALY. The treatment cost after liver transplantation from year 3 onwards was the most influential factor for ICERs, followed by the cost of terlipressin, duration of noradrenaline treatment, and cost of albumin. At the Thai societal willingness-to-pay threshold of 160,000 THB per QALY gained, the probabilities of being cost-effective for T+A, N+A, and BSC were 11%, 20%, and 69%, respectively.

Conclusion

The T+A and N+A treatments would not be cost-effective compared to BSC in the Thai setting.

Acute kidney injury and hepatorenal syndrome in cirrhosis

Acute kidney injury (AKI) in cirrhosis, including hepatorenal syndrome (HRS), is a common and serious complication in cirrhotic patients, leading to significant morbidity and mortality. AKI is separated into two categories, non-HRS AKI and HRS-AKI. The most recent definition and diagnostic criteria of AKI in cirrhosis and HRS have helped diagnose and prognosticate the disease. The pathophysiology behind non-HRS-AKI and HRS is more complicated than once theorized and involves more processes than just splanchnic vasodilation. The common biomarkers clinicians use to assess kidney injury have significant limitations in cirrhosis patients; novel biomarkers being studied have shown promise but require further studies in clinical settings and animal models. The overall management of non-HRS AKI and HRS-AKI requires a systematic approach. Although pharmacological treatments have shown mortality benefit, the ideal HRS treatment option is liver transplantation with or without simultaneous kidney transplantation. Further research is required to optimize pharmacologic and nonpharmacologic approaches to treatment. This article reviews the current guidelines and recommendations of AKI in cirrhosis.

Monitoring Renal Function and Therapy of Hepatorenal Syndrome Patients with Cirrhosis

Acute kidney injury (AKI) is a frequent complication in patients with cirrhosis. Patients with cirrhosis can develop AKI due to different causes. Hepatorenal syndrome (HRS) is a unique cause of AKI occurring in patients with advanced cirrhosis and is associated with high short-term mortality. The differential diagnosis between different causes of AKI may be challenging. In this regard, new urine biomarkers may be helpful. Liver transplantation is the definitive treatment of patients with HRS-AKI. Vasoconstrictors and albumin represent the first-line pharmacologic treatment of HRS-AKI. This review summarizes current knowledge for the diagnosis and management of HRS in cirrhosis.

An investigation of reconstituted terlipressin infusion stability for use in hepatorenal syndrome

Hepatorenal syndrome (HRS) is a fatal complication of renal dysfunction associated with ascites, liver failure and advanced cirrhosis. Although the best option for long-term survival is liver transplantation, in the critical acute phase, vasoconstrictors are considered first-line supportive agents. Terlipressin is the most widely used vasoconstrictor globally but owing to its short elimination half-life, it is usually administered six hourly by slow intravenous bolus injection. This requires patients to remain in hospital, increasing hospital bed costs and affecting their quality of life. An alternative option for administration of terlipressin is as a continuous infusion using an elastomeric infusor device in the patient’s home. However, stability data on terlipressin in elastomeric infusor devices is lacking. This research aimed to evaluate the stability of terlipressin reconstituted in infusor devices for up to 7 days at 2–8 °C and subsequently at 22.5 °C for 24 h, to mimic home storage and administration temperatures. We report that terlipressin was physically and chemically stable under these conditions; all reconstituted infusor concentrations retained above 90% of the original concentration over the test conditions. No colour change or precipitation in the solutions were evident.

Prevalence and short-term outcome of hepatorenal syndrome: A 9-year experience in a high-complexity hospital in Colombia

BACKGROUND & AIMS

Hepatorenal syndrome is a rare entity that is part of the complications of liver cirrhosis in its more severe stages. Without treatment, its mortality rate increases significantly. Terlipressin is considered to be the therapy of choice until the need of a liver transplant. The aim is to determine its prevalence, define patients' characteristics, triggers and 90-day survival, according to the type of managements established.

METHOD

This was a retrospective cohort study conducted in Colombia. It included patients with cirrhosis and acute kidney injury who met hepatorenal syndrome criteria, reaching 28 patients from 2007 to 2015. Groups were categorized according the type of hepatorenal syndrome and treatment. Demographic and trigger factors were evaluated to characterize the population. Treatment outcomes with terlipressin vs norepinephrine were analyzed up to a 90-day survival, using log Rank test. Continuous variables needed Student's T and Mann Whitney's U tests and categorical variables, Chi2 test. A value of p <0.05 and a power of 85% was considered. The data was analyzed in the SPSS version 23 software.

RESULTS

117 patients with cirrhosis developed renal injury; of these 23.9% were diagnosed with Hepatorenal Syndrome (67.8% type1; 32.1% type2). The presence of ascites was 100% in HRS2 and 84% in HRS1 (p = 0.296). The main trigger in both types was paracentesis greater than 5 liters in the last 4 weeks (39.3%). In total, 35% of the patients received renal replacement therapy and 14% underwent a hepatic transplant. Type 1 was more frequent (63% received terlipressin; 21% norepinephrine). The total complete response was 36% (Type2 66.6% vs. Type1 18.7%) (p = 0.026). In contrast, the overall mortality was of 67.8% at 90-day of follow-up (89.4% Type1 vs. 22% Type2) (p = <0.001). We found a lower mortality rate in patients treated with terlipressin than treated with norepinephrine (p = 0.006).

CONCLUSION

There is scarce clinical and epidemiological information about this condition in Colombia. A significant difference between the two drugs cannot be stipulated due to the limitation in the sample size of our study. The general mortality at a 90-day follow-up was high, being higher in patients with HRS1. While the results of this study are suggestive of clinical information for HRS patients in the Colombian population, they should also be interpreted with caution, therefore further multicenter studies should be performed.

Distant organ dysfunction in acute kidney injury

Acute kidney injury (AKI) is a common complication in critically ill patients and it is associated with increased morbidity and mortality. Epidemiological and clinical data show that AKI is linked to a wide range of distant organ injuries, with the lungs, heart, liver, and intestines representing the most clinically relevant affected organs. This distant organ injury during AKI predisposes patients to progression to multiple organ dysfunction syndrome and ultimately, death. The strongest direct evidence of distant organ injury occurring in AKI has been obtained from animal models. The identified mechanisms include systemic inflammatory changes, oxidative stress, increases in leucocyte trafficking and the activation of proapoptotic pathways. Understanding the pathways driving AKI-induced distal organ injury are critical for the development and refinement of therapies for the prevention and attenuation of AKI-related morbidity and mortality. The purpose of this review is to summarize both clinical and preclinical studies of AKI and its role in distant organ injury.

Impairment of natriuresis and diuresis induced by intrarenal adrenoceptor mechanisms in an experimental model of cirrhosis in rats

The contribution of intrarenal alpha-2 adrenergic receptors in mediating the enhanced renal excretory responses evoked by the alpha-2-agonist xylazine was examined in a model of cirrhosis in rats. In sham-operated rats, xylazine (0.2 mg/kg, i.v.) increased diuresis and natriuresis (urine flow, control: 78 ± 12.1, 10 min: 155 ± 17, 20 min: 194 ± 19, 30 min: 146 ± 16, 40 min: 114 ± 13, 50 min: 95 ± 10.5 μl/min/g; urinary sodium excretion, control: 6.75 ± 2.08, 10 min: 7.12 ± 2.1, 20 min: 13.4 ± 4.6, 30 min: 14.6 ± 4.02, 40 min: 12.05 ± 2.35, 50 min: 12.7 ± 2.45 μeq/min/g), which was accompanied by a significant reduction in renal sympathetic nerve activity (RSNA) (control: 100, 10 min: 39.5 ± 5.8, 20 min: 53 ± 8.8, 30 min: 72 ± 7.0, 40 min: 83 ± 5.0, 50 min: 94 ± 6.1 AU). Xylazine (0.2 mg/kg) in cirrhotic animals, despite resulting in a significant reduction in RSNA (control: 100, 10 min: 73 ± 4.3*, 20 min: 70 ± 5.0*, 30 min: 76 ± 7.0*, 40 min: 85 ± 5.5*, 50 min: 92 ± 4.8* AU), was unable to increase natriuresis. A higher dose (20 mg/kg) of xylazine was not capable of increasing natriuresis and diuresis, even in the presence of a robust reduction in RSNA. Renal denervation did not alter the onset and time course of cirrhosis. The results indicated that during the development of cirrhosis, there is an adaptive process that disables the intrarenal alpha-2 adrenoceptor mechanisms that selectively promote water and urinary sodium excretion via a sympathetic renal nerve-independent mechanism. Thus, in cirrhotic rats, the diuresis/natriuresis induced by xylazine is independent on RSNA. Intrarenal and/or hormonal changes are probably involved in the impairment of xylazine-induced diuresis/natriuresis in cirrhosis.

Hepatorenal syndrome in the era of acute kidney injury

Acute kidney injury (AKI) is a frequent complication of patients with advanced cirrhosis that it is associated with increased hospital admissions and decreased survival. The definition of AKI in cirrhosis has been recently modified and the new diagnostic criteria are based on small changes in serum creatinine with respect to previous values, occurring within a short period of time. The use of this new definition may lead to an earlier identification of renal impairment and better prognostic stratification. Hepatorenal syndrome (HRS) is a unique form of AKI developing in patients with end-stage liver disease. Systemic circulatory dysfunction and marked kidney vasoconstriction play a key role in the development of HRS. The modification of the definition of AKI has also led to a change in the diagnostic criteria of HRS. The new diagnostic criteria are based on AKI stages and there is no need to reach a specific serum creatinine threshold. According to these new criteria, treatment with vasoconstrictors and albumin for the management of HRS will be started at lower serum creatinine values, with expected higher response rates. Finally, there are consistent data showing that some urine biomarkers, particularly NGAL (neutrophil gelatinase-associated lipocalin), may be useful in daily clinical practice for the differential diagnosis of the cause of AKI in cirrhosis.

Hepatorenal syndrome

Hepatorenal syndrome (HRS) is a form of kidney function impairment that characteristically occurs in cirrhosis. Recent changes in terminology have led to acute HRS being referred to as acute kidney injury (AKI)-HRS and chronic HRS as chronic kidney disease (CKD)-HRS. AKI-HRS is characterized by a severe impairment of kidney function owing to vasoconstriction of the renal arteries in the absence of substantial abnormalities in kidney histology. Pathogenetic mechanisms involve disturbances in circulatory function due to a marked splanchnic arterial vasodilation, which triggers the activation of vasoconstrictor factors. An intense systemic inflammatory reaction that is characteristic of advanced cirrhosis may also be involved. The main triggering factors of AKI-HRS are bacterial infections, particularly spontaneous bacterial peritonitis. The diagnosis of AKI-HRS is a challenge because of a lack of specific diagnostic tools and mainly involves the differential diagnosis from other forms of AKI, particularly acute tubular necrosis. The prognosis of patients with AKI-HRS is poor, with a median survival of ≤3 months. The ideal treatment for AKI-HRS is liver transplantation in patients without contraindications. Medical therapy consists of vasoconstrictor drugs to counteract splanchnic arterial vasodilation together with volume expansion with albumin. Effective measures to prevent AKI-HRS include early identification and treatment of bacterial infections and the administration of albumin in patients with spontaneous bacterial peritonitis.

Extracorporeal organ support (ECOS) in critical illness and acute kidney injury: from native to artificial organ crosstalk

The complex nature of single organ failure potentially leading to multiple organ dysfunction syndrome (MODS) in critically ill patients necessitates integrated supportive therapy. Rather than a primary disease, acute kidney injury (AKI) is considered a window to a potentially serious underlying systemic disease, which may partially explain the high morbidity and mortality rates associated with the condition. Renal replacement therapy (RRT) has been routinely used for more than a decade in various intensive care settings and there has also been an increase in the use of extracorporeal membrane oxygenation and extracorporeal carbon dioxide removal. When these renal and cardiopulmonary modalities are used together, a multidisciplinary approach is necessary to minimize negative interactions and unwanted adverse effects. In this review, we describe the patterns of organ crosstalk between the native and artificial organs, the incidence of AKI and need for RRT and associated mortality after extracorporeal organ support (ECOS) therapy, including the potential short- and long-term advantages and disadvantages of organ support in terms of renal function. We also review potential indications of RRT outside its conventional indications in patients with MODS, as well as technical considerations when RRT is used alongside other organ support therapies. Overall, available literature has not definitely established the ideal timing of these interventions, and whether early implementation impacts organ recovery and optimizes resource utilization is still a matter of open debate: it is possible that future research will be devoted to identify patient groups that may benefit from short- and long-term multiple organ support.

New Developments in Hepatorenal Syndrome

Hepatorenal syndrome (HRS) continues to be one of the major complications of decompensated cirrhosis, leading to death in the absence of liver transplantation. Challenges in precisely evaluating renal function in the patient with cirrhosis remain because of the limitations of serum creatinine (Cr) alone in estimating glomerular filtration rate (GFR); current GFR estimating models appear to underestimate renal dysfunction. Newer models incorporating renal biomarkers, such as the Cr-Cystatin C GFR Equation for Cirrhosis appear to estimate measured GFR more accurately. A major change in the diagnostic criteria for HRS based on dynamic serial changes in serum Cr that regard HRS type 1 as a special form of acute kidney injury promises the possibility of earlier identification of renal dysfunction in patients with cirrhosis. The diagnostic criteria of HRS still include the exclusion of other causes of kidney injury. Renal biomarkers have been disappointing in assisting with the differentiation of HRS from prerenal azotemia and other kidney disorders. Serum metabolomic profiling may be a more powerful tool to assess renal dysfunction, although the practical clinical significance of this remains unclear. As a result of the difficulties of assessing renal function in cirrhosis and the varying HRS diagnostic criteria and the rigor with which they are applied, the precise incidence and prevalence of HRS is unknown, but it is likely that HRS occurs more commonly than expected. The pathophysiology of HRS is rooted firmly in the setting of progressive reduction in renal blood flow as a result of portal hypertension and splanchnic vasodilation. Progressive marked renal cortical ischemia in patients with cirrhosis parallels the evolution of diuretic-sensitive ascites to diuretic-refractory ascites and HRS, a recognized continuum of renal dysfunction in cirrhosis. Alterations in nitrous oxide production, both increased and decreased, may play a major role in the pathophysiology of this evolution. The inflammatory cascade, triggered by bacterial translocation and endotoxemia, increasingly recognized as important in the manifestation of acute-on-chronic liver failure, also may play a significant role in the pathophysiology of HRS. The mainstay of treatment remains vasopressor therapy with albumin in an attempt to reverse splanchnic vasodilation and improve renal blood flow. Several meta-analyses have confirmed the value of vasopressors, chiefly terlipressin and noradrenaline, in improving renal function and reversing HRS type 1. Other interventions such as renal replacement therapy, transjugular intrahepatic portosystemic shunt, and artificial liver support systems have a very limited role in improving outcomes in HRS. Liver transplantation remains the definitive treatment for HRS. The frequency of simultaneous liver-kidney transplantation has increased dramatically in the Model for End-stage Liver Disease era, with changes in organ allocation policies. This has resulted in a more urgent need to predict native kidney recovery from HRS after liver transplantation alone, to avoid unnecessary simultaneous liver-kidney transplantation.

Dual Organ Duel: The Hepatorenal Axis

Recent developments in our understanding of the pathogenesis of kidney disease in the setting of liver failure have highlighted that kidney injury, rather than occurring in isolation, is a marker of systemic disease and poor prognosis. The differential diagnosis of kidney disease associated with liver failure is broader than formerly described and new biopsy data, along with better acute kidney injury classification tools, have increased appreciation for distinct pathophysiological mechanisms. Evidence suggests that acute kidney injury contributes to worsening hepatic failure by directly injuring hepatic cells and by imposing restrictions on therapeutic strategies for portal hypertension. Furthermore, kidney injury limits the use of various therapeutic agents and increases their toxicity due to altered pharmacodynamics. A greater appreciation of CKD in this population is also overdue because management decisions are affected and increased vigilance may avoid further kidney injury. A multidisciplinary approach to kidney injury in the setting of liver failure will enable targeted therapeutic strategies that are safe and effective and serve to guide further research, while limiting clinical potential for harm. Finally, new hepatitis C antiviral therapies promise to change the landscape of liver failure, and a discussion of kidney risk factors and antiviral therapy of patients with kidney disease and hepatitis C is worthwhile.

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

BACKGROUND

The goal of hepatorenal syndrome type 1 (HRS-1) treatment is to improve renal function. Terlipressin, a synthetic vasopressin analogue, is a systemic vasoconstrictor used for the treatment of HRS-1, where it is available.

AIM

To compare the efficacy of terlipressin plus albumin vs. placebo plus albumin in patients with HRS-1.

METHODS

Pooled patient-level data from two large phase 3, randomised, placebo-controlled studies were analysed for HRS reversal [serum creatinine (SCr) value ≤133 μmol/L], 90-day survival, need for renal replacement therapy and predictors of HRS reversal. Patients received intravenous terlipressin 1-2 mg every 6 hours plus albumin or placebo plus albumin up to 14 days.

RESULTS

The pooled analysis comprised 308 patients (terlipressin: n = 153; placebo: n = 155). HRS reversal was significantly more frequent with terlipressin vs. placebo (27% vs. 14%; P = 0.004). Terlipressin was associated with a more significant improvement in renal function from baseline until end of treatment, with a mean between-group difference in SCr concentration of -53.0 μmol/L (P < 0.0001). Lower SCr, lower mean arterial pressure and lower total bilirubin and absence of known precipitating factors for HRS were independent predictors of HRS reversal and longer survival in terlipressin-treated patients.

CONCLUSIONS

Terlipressin plus albumin resulted in a significantly higher rate of HRS reversal vs. albumin alone in patients with HRS-1. Terlipressin treatment is associated with improved renal function. (ClinicalTrials.gov identifier: OT-0401, NCT00089570; REVERSE, NCT01143246).

Challenges in Renal Failure Treatment Before Liver Transplant

Acute kidney injury (AKI) is common in patients with cirrhosis and ascites on the waiting list for liver transplant. Hepatorenal syndrome (HRS) is an important cause of AKI among cirrhotics. A dynamic definition of AKI in patients with cirrhosis has been introduced and changed the diagnosis criteria. Liver transplantation remains the better option but the medical management of HRS has changed. Terlipressin plus albumin is currently the gold standard. Surgery and liver or kidney support systems have been recommended. Clinical trials will assess the most appropriate approach for the treatment of HRS in light of the revised diagnostic criteria.

Renal dysfunction in cirrhosis: acute kidney injury and the hepatorenal syndrome

Renal dysfunction is a common complication of liver cirrhosis and of utmost clinical and prognostic relevance. Patients with cirrhosis are more prone to developing acute kidney injury (AKI) than the non-cirrhotic population. Pre-renal AKI, the hepatorenal syndrome type of AKI (HRS-AKI, formerly known as 'type 1') and acute tubular necrosis represent the most common causes of AKI in cirrhosis. Correct differentiation is imperative, as treatment differs substantially. While pre-renal AKI usually responds well to plasma volume expansion, HRS-AKI and ATN require different specific approaches and are associated with substantial mortality. Several paradigms, such as the threshold of 2.5 mg/dL for diagnosis of HRS-AKI, have recently been abolished and novel urinary biomarkers are being investigated in order to facilitate early and correct diagnosis and treatment of HRS-AKI and other forms of AKI in patients with cirrhosis. This review summarizes the current diagnostic criteria, as well as pathophysiologic and therapeutic concepts for AKI and HRS-AKI in cirrhosis.

Therapeutic alternatives for the treatment of type 1 hepatorenal syndrome: A Delphi technique-based consensus

AIM

To propose several alternatives treatment of type 1 hepatorenal syndrome (HRS-1) what is the most severe expression of circulatory dysfunction on patients with portal hypertension.

METHODS

A group of eleven gastroenterologists and nephrologists performed a structured analysis of available literature. Each expert was designated to review and answer a question. They generated draft statements for evaluation by all the experts. Additional input was obtained from medical community. In order to reach consensus, a modified three-round Delphi technique method was used. According to United States Preventive Services Task Force criteria, the quality of the evidence and level of recommendation supporting each statement was graded.

RESULTS

Nine questions were formulated. The available evidence was evaluated considering its quality, number of patients included in the studies and the consistency of its results. The generated questions were answered by the expert panel with a high level of agreement. Thus, a therapeutic algorithm was generated. The role of terlipressin and norepinephrine was confirmed as the pharmacologic treatment of choice. On the other hand the use of the combination of octreotide, midodrine and albumin without vasoconstrictors was discouraged. The role of several other options was also evaluated and the available evidence was explored and discussed. Liver transplantation is considered the definitive treatment for HRS-1. The present consensus is an important effort that intends to organize the available strategies based on the available evidence in the literature, the quality of the evidence and the benefits, adverse effects and availability of the therapeutic tools described.

CONCLUSION

Based on the available evidence the expert panel was able to discriminate the most appropriate therapeutic alternatives for the treatment of HRS-1.

Terlipressin Plus Albumin Is More Effective Than Albumin Alone in Improving Renal Function in Patients With Cirrhosis and Hepatorenal Syndrome Type 1

BACKGROUND & AIMS

Hepatorenal syndrome type 1 (HRS-1) in patients with cirrhosis and ascites is a functional, potentially reversible, form of acute kidney injury characterized by rapid (<2 wk) and progressive deterioration of renal function. Terlipressin is a synthetic vasopressin analogue that acts, via vascular vasopressin V1 receptors, as a systemic vasoconstrictor. We performed a phase 3 study to evaluate the efficacy and safety of intravenous terlipressin plus albumin vs placebo plus albumin in patients with HRS-1.

METHODS

Adult patients with cirrhosis, ascites, and HRS-1 (based on the 2007 International Club of Ascites criteria of rapidly deteriorating renal function) were assigned randomly to groups given intravenous terlipressin (1 mg, n = 97) or placebo (n = 99) every 6 hours with concomitant albumin. Treatment continued through day 14 unless the following occurred: confirmed HRS reversal (CHRSR, defined as 2 serum creatinine [SCr] values ≤1.5 mg/dL, at least 40 hours apart, on treatment without renal replacement therapy or liver transplantation) or SCr at or above baseline on day 4. The primary end point was the percentage of patients with confirmed CHRSR. Secondary end points included the incidence of HRS reversal (defined as at least 1 SCr value ≤1.5 mg/dL while on treatment), transplant-free survival, and overall survival. The study was performed at 50 investigational sites in the United States and 2 in Canada, from October 2010 through February 2013.

RESULTS

Baseline demographic/clinical characteristics were similar between groups. CHRSR was observed in 19 of 97 patients (19.6%) receiving terlipressin vs 13 of 99 patients (13.1%) receiving placebo (P = .22). HRS reversal was achieved in 23 of 97 (23.7%) patients receiving terlipressin vs 15 of 99 (15.2%) receiving placebo (P = .13). SCr decreased by 1.1 mg/dL in patients receiving terlipressin and by only 0.6 mg/dL in patients receiving placebo (P < .001). Decreases in SCr and survival were correlated (r(2) = .882; P < .001). Transplant-free and overall survival were similar between groups. A significantly greater proportion of patients with CHRSR who received terlipressin survived until day 90 than patients who did not have CHRSR after receiving terlipressin (P < .001); this difference was not observed in patients who did vs did not have CHRSR after receiving placebo (P = .28). There were similar numbers of adverse events in each group, but patients in the terlipressin group had more ischemic events.

CONCLUSIONS

Terlipressin plus albumin was associated with greater improvement in renal function vs albumin alone in patients with cirrhosis and HRS-1. Patients had similar rates of HRS reversal with terlipressin as they did with albumin. ClinicalTrials.gov no: NCT01143246.

[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.

Development of a rat model of D-galactosamine/lipopolysaccharide induced hepatorenal syndrome

AIM: To develop a practical and reproducible rat model of hepatorenal syndrome for further study of the pathophysiology of human hepatorenal syndrome.

METHODS: Sprague-Dawley rats were intravenously injected with D-galactosamine and lipopolysaccharide (LPS) via the tail vein to induce fulminant hepatic failure to develop a model of hepatorenal syndrome. Liver and kidney function tests and plasma cytokine levels were measured after D-galactosamine/LPS administration, and hepatic and renal pathology was studied. Glomerular filtration rate was detected in conscious rats using micro-osmotic pump technology with fluorescein isothiocyanate-labelled inulin as a surrogate marker.

RESULTS: Serum levels of biochemical indicators including liver and kidney function indexes and cytokines all significantly changed, especially at 12 h after D-galactosamine/LPS administration [alanine aminotransferase, 3389.5 ± 499.5 IU/L; blood urea nitrogen, 13.9 ± 1.3 mmol/L; Cr, 78.1 ± 2.9 μmol/L; K⁺, 6.1 ± 0.5 mmol/L; Na⁺, 130.9 ± 1.9 mmol/L; Cl^-, 90.2 ± 1.9 mmol/L; tumor necrosis factor-α, 1699.6 ± 599.1 pg/mL; endothelin-1, 95.9 ± 25.9 pg/mL; P < 0.05 compared with normal saline control group]. Hepatocyte necrosis was aggravated gradually, which was most significant at 12 h after treatment with D-galactosamine/LPS, and was characterized by massive hepatocyte necrosis, while the structures of glomeruli, proximal and distal tubules were normal. Glomerular filtration rate was significantly decreased to 30%-35% of the control group at 12 h after D-galactosamine/LPS administration [Glomerular filtration rate (GFR)₁, 0.79 ± 0.11 mL/min; GFR₂, 3.58 ± 0.49 mL/min·kgBW^-1; GFR₃, 0.39 ± 0.99 mL/min·gKW^-1]. The decreasing timing of GFR was consistent with that of the presence of hepatocyte necrosis and liver and kidney dysfunction.

CONCLUSION: The joint use of D-galactosamine and LPS can induce liver and kidney dysfunction and decline of glomerular filtration rate in rats which is a successful rat model of hepatorenal syndrome.

Management options in decompensated cirrhosis

Chronic injury to the liver from a variety of different sources can result in irreversible scarring of the liver, known as cirrhosis. Cirrhosis is a major cause of morbidity and mortality in the USA, and according to the Centers for Disease Control and Prevention was responsible for 31,903 deaths in 2010 alone. It is thus of the utmost importance to appropriately manage these patients in the inpatient and outpatient setting to improve morbidity and mortality. In this review, we address four major areas of cirrhosis management: outpatient management of portal hypertension with decompensation, hepatic encephalopathy, hepatorenal syndrome, and bleeding/coagulation issues. Outpatient management covers recommendations for health care maintenance and screening. Hepatic encephalopathy encompasses a brief review of pathophysiology, treatment in the acute setting, and long-term prevention. Hepatorenal syndrome is discussed in regards to pathophysiology and treatment in the hospital setting. Finally, a discussion of the assessment of coagulation profiles in cirrhosis and recommendations for bleeding and thrombosis complications is included. These topics are not all encompassing with regard to this complicated population, but rather an overview of a few medical problems that are commonly encountered in their care.

From the nephrologist's point of view: diversity of causes and clinical features of acute kidney injury

Acute kidney injury (AKI) is a clinical syndrome with multiple entities. Although AKI implies renal damage, functional impairment or both, diagnosis is solely based on the functional parameters of serum creatinine and urine output. The latest definition was provided by the Kidney Disease Improving Global Outcomes (KDIGO) working group in 2012. Independent of the underlying disease, and even in the case of full recovery, AKI is associated with an increased morbidity and mortality. Awareness of the patient's individual risk profile and the diversity of causes and clinical features of AKI is pivotal for optimization of prophylaxes, diagnosis and therapy of each form of AKI. A differentiated and individualized approach is required to improve patient mortality, morbidity, long-term kidney function and eventually the quality of life. In this review, we provide an overview of the different clinical settings in which specific forms of AKI may occur and point out possible diagnostic as well as therapeutic approaches. Secifically AKI is discussed in the context of non-kidney organ failure, organ transplantation, sepsis, malignancy and autoimmune disease.

Challenges and Management of Liver Cirrhosis: Pathophysiology of Renal Dysfunction in Cirrhosis

Kidney dysfunction is a common complication of patients with advanced cirrhosis and is associated with poor prognosis. Patients with advanced cirrhosis show circulatory dysfunction characterized by reduced systemic vascular resistance due to splanchnic arterial vasodilation, which is caused by portal hypertension. The progressive reduction in systemic vascular resistance leads to effective arterial hypovolemia. In order to maintain arterial pressure within normal limits in this setting, there is activation of systemic vasoconstrictor systems, including the renin-angiotensin-aldosterone system, sympathetic nervous system and, in late stages, nonosmotic hypersecretion of vasopressin. Although these systems have positive effects in maintaining arterial pressure, they have a negative influence on kidney function, leading to the retention of sodium and solute-free water, and in late stages of the disease an intense kidney vasoconstriction develops, leading to decrease of the glomerular filtration rate and the development of hepatorenal syndrome (HRS). Moreover, bacterial translocation and the existence of a systemic inflammatory state in patients with advanced cirrhosis may play a role in the impairment of circulatory function. HRS is a unique cause of kidney failure of functional origin that develops in patients with cirrhosis. However, besides HRS, patients with cirrhosis may develop kidney failure due to other causes, including bacterial infections, prerenal kidney failure, shock, use of nephrotoxic drugs or intrinsic kidney diseases. Considering the existence of circulatory dysfunction and some degree of kidney vasoconstriction, patients with advanced cirrhosis have fragile kidney function and are susceptible to easily developing kidney failure associated with other complications of the disease, particularly bacterial infections and gastrointestinal bleeding.

Treatment and management of ascites and hepatorenal syndrome: an update

Ascites and renal dysfunction are frequent complications experienced by patients with cirrhosis of the liver. Ascites is the pathologic accumulation of fluid in the peritoneal cavity, and is one of the cardinal signs of portal hypertension. The diagnostic evaluation of ascites involves assessment of its granulocyte count and protein concentration to exclude complications such as infection or malignoma and to allow risk stratification for the development of spontaneous peritonitis. Although sodium restriction and diuretics remain the cornerstone of the management of ascites, many patients require additional therapy when they become refractory to this treatment. In this situation, the treatment of choice is repeated large-volume paracentesis. Alteration in splanchnic hemodynamics is one of the most important changes underlying the development of ascites. Further splanchnic dilation leads to changes in systemic hemodynamics, activating vasopressor agents and leading to decreased renal perfusion. Small alterations in renal function influence the prognosis, which depends on the cause of renal failure. Prerenal failure is evident in about 70% of patients, whereas in about 30% of patients the cause is hepatorenal syndrome (HRS), which is associated with a worse prognosis. Therefore, effective therapy is of great clinical importance. Recent data indicate that use of the new definition of acute kidney injury facilitates the identification and treatment of patients with renal insufficiency more rapidly than use of the current criteria for HRS. In this review article, we evaluate approaches to the management of patients with ascites and HRS.

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.

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.

Post-paracentesis circulatory derangements are related to monocyte activation

BACKGROUND & AIMS

Post-paracentesis circulatory dysfunction is associated with development of hepatorenal syndrome and increased mortality. The impact of large volume paracentesis (LVP) on the 24-h blood pressure (BP) profile is unknown, and the relationship to Na+-retentive and pro-inflammatory cytokines also remains unknown. The aims of this study were to (i) define the effects of LVP with albumin administration on 24-h BP profiles, and (ii) relate changes in BP over time to changes in Na+-retentive hormones, clinical factors and inflammatory cytokines.

METHODS

Ten patients undergoing LVP had 24-h ambulatory BP monitoring performed pre- and post-paracentesis. Markers of the innate immune system, bacterial translocation and Na+-retentive hormones were drawn pre- and post-LVP.

RESULTS

Mean arterial pressure (MAP) dropped in nine of the 10 patients in the 24 h following a paracentesis compared to 24 h preceding the procedure (mean drop of 5.5 mmHg, P<0.005). A mixed effects model was used to define time-covariate interactions in predicting changes in BP profile. Monocyte chemotactic protein-1 (MCP1) was associated with Δsystolic BP (β=-0.011, P<0.05), Δdiastolic BP (β=-0.012, P<0.05) and ΔMAP (β=-0.012, P<0.05). Plasma renin activity was also significantly associated with Δsystolic BP (β=-0.21, P<0.05). Renal function was also significantly reduced following LVP.

CONCLUSIONS

Systolic, diastolic and MAP decreased over 24 h after LVP compared to the 24 h pre-LVP. This drop is related to increases in MCP-1 after LVP. Increased MCP-1, a marker of monocyte activation, was strongly related to changes in BP.

Renal dysfunction in end-stage liver disease and post-liver transplant

Renal dysfunction is a frequent complication in patients with end-stage liver disease awaiting orthotopic liver transplantation and in the post-liver transplant period. Although the stereotypical form of renal dysfunction is the hepatorenal syndrome, other causes of acute kidney injury in this population include prerenal azotemia and acute tubular necrosis. Renal injury in a patient with cirrhosis is associated with a poor prognosis.

[Baclofen and liver cirrhosis: literature review and safety precautions implemented within the system CAMTEA]

The off-label prescribing of high dose baclofen (HDB) has been recently spreading in France. The impact of HDB on subjects with liver cirrhosis remains poorly known. The main pharmacodynamic and pharmacokinetic data on baclofen result from studies on healthy subjects or using low doses of treatment. The specific biodisponibility and elimination of HDB have not been studied yet in cirrhosis. National pharmacovigilance reports suggest that a careful use of baclofen or even HDB could be possible in compensated cirrhosis. However, theoretical risks of baclofen overdose exist in cases of hepatorenal syndrome or portosystemic shunt. Baclofen could also induce a specific pharmacological potentiation of hepatic encephalopathy and gastropathy. Within CAMTEA, a regional team-based multidisciplinary system for delivering and monitoring off-label medications in alcohol use disorders, a set of predefined precautions for using baclofen in cirrhosis have been implemented, until further information becomes available. These precautions notably consist of a protocolized process for declaring adverse events, and a hepatologic follow-up associated with the usual multidisciplinary care system set up within CAMTEA.

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.

Physiologically based pharmacokinetic models for the optimization of antiretroviral therapy: recent progress and future perspective

Anti-HIV therapy is characterized by the chronic administration of antiretrovirals (ARVs), and consequently, several problems can arise during the management of HIV-positive patients. ARV disposition can be simulated by combining system data describing a population of patients and in vitro drug data through physiologically based pharmacokinetic (PBPK) models, which mathematically describe absorption, distribution, metabolism and elimination. PBPK modeling can find application in the investigation of clinically relevant scenarios, while providing the opportunity for a better understanding of the mechanisms regulating drug distribution. In this review, we have analyzed the most recent applications of PBPK models for ARVs and highlighted some of the most interesting areas of use, such as drug–drug interaction, pharmacogenetics, factors regulating absorption and tissue penetration, as well as therapy optimization in special populations. The application of the PBPK modeling approach might not be limited to the investigation of hypothetical clinical issues, but could be used to inform future prospective clinical trials.

Predictors of renal recovery in patients with pre-orthotopic liver transplant (OLT) renal dysfunction

BACKGROUND

Renal dysfunction occurs commonly in patients awaiting orthotopic liver transplantation (OLT) for end-stage liver disease. The use of simultaneous liver-kidney transplantation has increased in the MELD scoring era. As patients may recover renal function after OLT, identifying factors predictive of renal recovery is a critical issue, especially given the scarcity of available organs.

METHODS

Employing the UNOS database, we sought to identify donor- and patient-related predictors of renal recovery among 1720 patients with pre-OLT renal dysfunction and transplanted from 1989 to 2005. Recovery of renal function post-OLT was defined as a composite endpoint of serum creatinine (SCr) ≤1.5 mg/dL at discharge and survival ≥29 days. Pre-OLT renal dysfunction was defined as any of the following: SCr ≥2 mg/dL at any time while awaiting OLT or need for renal replacement therapy (RRT) at the time of registration and/or OLT.

RESULTS

Independent predictors of recovery of renal function post-OLT were absence of hepatic allograft dysfunction, transplantation during MELD era, recipient female sex, decreased donor age, decreased recipient ALT at time of OLT, decreased recipient body mass index at registration, use of anti-thymocyte globulin as induction therapy, and longer wait time from registration. Contrary to popular belief, a requirement for RRT, even for prolonged periods in excess of 8 weeks, was not an independent predictor of failure to recover renal function post-OLT.

CONCLUSION

These data indicate that the duration of renal dysfunction, even among those requiring RRT, is a poor way to discriminate reversible from irreversible renal dysfunction.

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.

Anaesthesia for Living Related Liver Transplantation

With the greater success of liver transplantation, livers from deceased donors are insufficient to meet the need for livers required for transplantation. In various parts of Asia, living related liver transplantation is the treatment for patients with end-stage liver disease. An overview of anaesthesia for both the donor and the recipient is described. Controversies involving epidural anaesthesia, blood loss prevention and blood conservation techniques in the donor are discussed. Various aspects in the anaesthetic management of the recipient are also looked at.