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Malik A, Malik MI, Qureshi S, Nadir A. Efficacy and safety of terlipressin and albumin vs. noradrenaline and albumin in adult patients with hepatorenal syndrome: A systematic review and meta-analysis. Ann Hepatol 2024:101495. [PMID: 38460713 DOI: 10.1016/j.aohep.2024.101495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/10/2023] [Accepted: 01/03/2024] [Indexed: 03/11/2024]
Abstract
INTRODUCTION AND OBJECTIVES Hepatorenal syndrome (HRS) is a serious complication of cirrhosis treated with several medications. We want to evaluate terlipressin and albumin's effectiveness and safety compared to albumin and noradrenaline in adult hepatorenal disease patients. MATERIALS AND METHODS Clinical trials from four databases were included. Cochrane's approach for calculating bias risk was utilized. We rated the quality evaluation by Grading of Recommendations Assessment, Development, and Evaluation (GRADE). We included the following outcomes: Serum creatinine (mg/dl), Urine output (ml/24 h), Mean arterial pressure (mmHg), Reversal rate of HRS, Mortality rate, Serum sodium (mEq/l), Blood plasma renin activity (ng/ml/h), plasma aldosterone concentration (pg/ml), urine sodium (mEq/l), and creatinine clearance (ml/min). RESULTS Our analysis of nine clinical studies revealed that the noradrenaline group was linked to a considerable decrease in serum sodium (MD = 1.38 [0.16, 2.60]), (P = 0.03) and increased creatinine clearance that is noticeable (MD = 4.22 [0.40, 8.05]), (P = 0.03). There were no significant differences in serum creatinine levels (MD = 0.03 [-0.07, 0.13]), urinary sodium (MD = -1.02 [-5.15, 3.11]), urine output (MD = 32.75 [-93.94, 159.44]), mean arterial pressure (MD = 1.40 [-1.17, 3.96]), plasma renin activity (MD = 1.35 [-0.17, 2.87]), plasma aldosterone concentration (MD = 55.35 [-24.59, 135.29]), reversal rate of HRS (RR = 1.15 [0.96, 1.37]), or mortality rate (RR = 0.87 [0.74, 1.01]) between the two groups (p-values > 0.05). CONCLUSIONS Noradrenaline is a safe and comparable therapy to terlipressin for HRS.
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Affiliation(s)
- Adnan Malik
- Division of Gastroenterology, Mountain Vista Medical Center, Mesa, AZ, United States.
| | | | - Shahbaz Qureshi
- Division of Gastroenterology, Mountain Vista Medical Center, Mesa, AZ, United States
| | - Abdul Nadir
- Division of Gastroenterology, Mountain Vista Medical Center, Mesa, AZ, United States
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2
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Erstad BL. Hepatorenal Syndrome With Acute Kidney Injury: Diagnosis and Medical Management. Ann Pharmacother 2024; 58:156-164. [PMID: 37271967 DOI: 10.1177/10600280231177698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
OBJECTIVES To review the current definitions and diagnostic criteria for acute kidney injury (AKI) and type 1 hepatorenal syndrome (HRS) now termed HRS-AKI and discuss the challenges in deciding the most appropriate medication regimens to treat patients with HRS-AKI. DATA SOURCES PubMed (inception to April 2023) with bibliographies of retrieved articles searched for additional articles; organizational websites for clinical practice guidelines (CPGs). STUDY SELECTION AND DATA EXTRACTION Randomized controlled trials (RCTs) evaluating albumin and vasoconstrictors for HRS-AKI. DATA SYNTHESIS A major change in the most recent revision of definitions and diagnostic criteria for HRS-AKI is the elimination of the set cutoff serum creatinine values for AKI. This change should be considered when comparing studies of HRS-AKI over time. Albumin has been administered to both vasoconstrictor treatment and placebo groups in all recent RCTs; however, there has never been a large RCT evaluating a no-albumin group. Most prospective trials comparing a midodrine/octreotide combination or norepinephrine to placebo or terlipressin have enrolled less than 100 patients limiting any conclusions regarding clinically important outcomes. Terlipressin with albumin has shown mixed results for complete HRS-AKI reversal with no reductions in crude mortality but adverse effect concerns involving ischemic and pulmonary events. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Type 1 hepatorenal syndrome with acute kidney injury is a potentially life-threatening syndrome with diagnostic and treatment challenges. Albumin plus a vasoconstrictor has become the routine HRS-AKI treatment even though there has not been a large RCT evaluating a no-albumin group. Terlipressin is the vasoconstrictor of choice for HRS-AKI in current CPGs, but it has adverse effect concerns and, until recently, was not available in the United States. CONCLUSIONS In conjunction with changes in the definitions and diagnostic criteria for HRS-AKI, debate continues regarding the optimal therapy for HRS-AKI, particularly considering recent trials demonstrating ischemic and pulmonary adverse events with terlipressin used in combination with albumin.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, R. Ken Coit College of Pharmacy, University of Arizona, Tucson, AZ, USA
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Castillo GM, Yao Y, Guerra RE, Jiang H, Nishimoto-Ashfield A, Lyubimov AV, Alfaro JF, Striker KA, Buynov N, Schwabl P, Bolotin EM. Subcutaneous therapy for portal hypertension: PHIN-214, a partial vasopressin receptor 1A agonist. Biomed Pharmacother 2024; 171:116068. [PMID: 38176129 PMCID: PMC10953113 DOI: 10.1016/j.biopha.2023.116068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/14/2023] [Accepted: 12/21/2023] [Indexed: 01/06/2024] Open
Abstract
Cirrhosis is a liver disease that leads to increased intrahepatic resistance, portal hypertension (PH), and splanchnic hyperemia resulting in ascites, variceal bleeding, and hepatorenal syndrome. Terlipressin, a prodrug that converts to a short half-life vasopressin receptor 1 A (V1a) full agonist [8-Lys]-Vasopressin (LVP), is an intravenous treatment for PH complications, but hyponatremia and ischemic side effects require close monitoring. We developed PHIN-214 which converts into PHIN-156, a more biologically stable V1a partial agonist. PHIN-214 enables once-daily subcutaneous administration without causing ischemia or tissue necrosis and has a 10-fold higher therapeutic index than terlipressin in healthy rats. As V1a partial agonists, PHIN-214 and PHIN-156 exhibited maximum activities of 28 % and 42 % of Arginine vasopressin (AVP), respectively. The potency of PHIN-156 and LVP relative to AVP is comparable for V1a (5.20 and 1.65 nM, respectively) and V1b (102 and 115 nM, respectively) receptors. However, the EC50 of PHIN-156 to the V2 receptor was 26-fold higher than that of LVP, indicating reduced potential for dilutional hyponatremia via V2 agonism compared to terlipressin/LVP. No significant off-target binding to 87 toxicologically relevant receptors were observed when evaluated in vitro at 10 µM concentration. In bile duct ligated rats with PH, subcutaneous PHIN-214 reduced portal pressure by 13.4 % ± 3.4 in 4 h. These collective findings suggest that PHIN-214 could be a novel pharmacological treatment for patients with PH, potentially administered outside of hospital settings, providing a safe and convenient alternative for managing PH and its complications.
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Affiliation(s)
| | - Yao Yao
- PharmaIN Corp., Bothell, Washington 98011, USA
| | | | - Han Jiang
- PharmaIN Corp., Bothell, Washington 98011, USA
| | | | - Alexander V Lyubimov
- University of Illinois, Toxicology Research Laboratory, Department of Pharmacology, Chicago 60612, USA
| | | | | | | | - Philipp Schwabl
- Medical University of Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Vienna, Austria
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4
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Qi X, Bai Z, Zhu Q, Cheng G, Chen Y, Dang X, Ding H, Han J, Han L, He Y, Ji F, Jin H, Li B, Li H, Li Y, Li Z, Liu B, Liu F, Liu L, Lin S, Ma D, Meng F, Qi R, Ren T, Shao L, Tang S, Tang Y, Teng Y, Wang C, Wang R, Wu Y, Xu X, Yang L, Yuan J, Yuan S, Yang Y, Zhao Q, Zhang W, Yang Y, Guo X, Xie W. Practice guidance for the use of terlipressin for liver cirrhosis-related complications. Therap Adv Gastroenterol 2022; 15:17562848221098253. [PMID: 35601800 PMCID: PMC9121451 DOI: 10.1177/17562848221098253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/12/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Liver cirrhosis is a major global health burden worldwide due to its high risk of morbidity and mortality. Role of terlipressin for the management of liver cirrhosis-related complications has been recognized during recent years. This article aims to develop evidence-based clinical practice guidance on the use of terlipressin for liver cirrhosis-related complications. METHODS Hepatobiliary Study Group of the Chinese Society of Gastroenterology of the Chinese Medical Association and Hepatology Committee of the Chinese Research Hospital Association have invited gastroenterologists, hepatologists, infectious disease specialists, surgeons, and clinical pharmacists to formulate the clinical practice guidance based on comprehensive literature review and experts' clinical experiences. RESULTS Overall, 10 major guidance statements regarding efficacy and safety of terlipressin in liver cirrhosis were proposed. Terlipressin can be beneficial for the management of cirrhotic patients with acute variceal bleeding and hepatorenal syndrome (HRS). However, the evidence regarding the use of terlipressin in cirrhotic patients with ascites, post-paracentesis circulatory dysfunction, and bacterial infections and in those undergoing hepatic resection and liver transplantation remains insufficient. Terlipressin-related adverse events, mainly including gastrointestinal symptoms, electrolyte disturbance, and cardiovascular and respiratory adverse events, should be closely monitored. CONCLUSION The current clinical practice guidance supports the use of terlipressin for gastroesophageal variceal bleeding and HRS in liver cirrhosis. High-quality studies are needed to further clarify its potential effects in other liver cirrhosis-related complications.
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Affiliation(s)
| | | | | | - Gang Cheng
- Department of Life Sciences and
Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Yu Chen
- Difficult and Complicated Liver Diseases and
Artificial Liver Center, Beijing You’an Hospital, Capital Medical
University, Beijing, China
| | - Xiaowei Dang
- Department of Hepatobiliary and Pancreatic
Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou,
China
| | - Huiguo Ding
- Department of Gastrointestinal and Hepatology,
Beijing You’An Hospital, Capital Medical University, Beijing, China
| | - Juqiang Han
- Institute of Liver Disease, The 7th Medical
Centre of Chinese People Liberation Army General Hospital, Beijing,
China
| | - Lei Han
- Department of Hepatobiliary Surgery, General
Hospital of Northern Theater Command, Shenyang, China
| | - Yingli He
- Department of Infectious Diseases, First
Affiliated Teaching Hospital, Xi’an Jiaotong University, Xi’an, China
| | - Fanpu Ji
- Department of Infectious Diseases, The Second
Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Hongxu Jin
- Department of Emergency Medicine, General
Hospital of Northern Theater Command, Shenyang, China
| | - Bimin Li
- Department of Gastroenterology, The First
Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hongyu Li
- Department of Gastroenterology, General
Hospital of Northern Theater Command, Shenyang, China
| | - Yiling Li
- Department of Gastroenterology, First
Affiliated Hospital of China Medical University, Shenyang, China
| | - Zhiwei Li
- Department of Hepato-Biliary Surgery, Shenzhen
Third People’s Hospital, Shenzhen, China
| | - Bang Liu
- Department of Hepatobiliary Disease, 900
Hospital of the Joint Logistics Team, Fuzhou, China
| | - Fuquan Liu
- Department of Interventional Radiology,
Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Lei Liu
- Department of Gastroenterology, Tangdu
Hospital of the Fourth Military Medical University, Xi’an, China
| | - Su Lin
- Liver Research Center, The First Affiliated
Hospital of Fujian Medical University, Fuzhou, China
| | - Dapeng Ma
- Department of Critical Care Medicine, The
Sixth People’s Hospital of Dalian, Dalian, China
| | - Fanping Meng
- Department of Infectious Diseases, The Fifth
Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Ruizhao Qi
- Department of General Surgery, The Fifth
Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Tianshu Ren
- Department of Pharmacy, General Hospital of
Northern Theater Command, Shenyang, China
| | - Lichun Shao
- Department of Gastroenterology, Air Force
Hospital of Northern Theater Command, Shenyang, China
| | - Shanhong Tang
- Department of Gastroenterology, General
Hospital of Western Theater Command, Chengdu, China
| | - Yufu Tang
- Department of Hepatobiliary Surgery, General
Hospital of Northern Theater Command, Shenyang, China
| | - Yue Teng
- Department of Emergency Medicine, General
Hospital of Northern Theater Command, Shenyang, China
| | - Chunhui Wang
- Department of Hepatobiliary Surgery, General
Hospital of Northern Theater Command, Shenyang, China
| | - Ran Wang
- Department of Gastroenterology, General
Hospital of Northern Theater Command, Shenyang, China
| | - Yunhai Wu
- Department of Critical Care Medicine, Sixth
People’s Hospital of Shenyang, Shenyang, China
| | - Xiangbo Xu
- Department of Gastroenterology, General
Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and
Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Ling Yang
- Department of Gastroenterology, Union
Hospital, Tongji Medical College, Huazhong University of Science and
Technology, Wuhan, China
| | - Jinqiu Yuan
- Clinical Research Center, The Seventh
Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Shanshan Yuan
- Department of Gastroenterology, Xi’an Central
Hospital, Xi’an, China
| | - Yida Yang
- Collaborative Innovation Center for Diagnosis
and Treatment of Infectious Diseases, The First Affiliated Hospital,
Zhejiang University School of Medicine, Hangzhou, China
| | - Qingchun Zhao
- Department of Pharmacy, General Hospital of
Northern Theater Command, Shenyang, China
| | - Wei Zhang
- Department of Hepatobiliary Surgery, General
Hospital of Northern Theater Command, Shenyang, China
| | - Yongping Yang
- Department of Liver Disease, The Fifth Medical
Center of Chinese PLA General Hospital, 100 West Fourth Ring Middle Road,
Beijing 100039, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General
Hospital of Northern Theater Command, 83 Wenhua Road, Shenyang 110015,
Liaoning, China
| | - Weifen Xie
- Department of Gastroenterology, Changzheng
Hospital, Naval Medical University, Shanghai 200003, China
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5
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Belcher JM, Parada XV, Simonetto DA, Juncos LA, Karakala N, Wadei HM, Sharma P, Regner KR, Nadim MK, Garcia-Tsao G, Velez JCQ, Parikh SM, Chung RT, Allegretti AS. Terlipressin and the Treatment of Hepatorenal Syndrome: How the CONFIRM Trial Moves the Story Forward. Am J Kidney Dis 2021; 79:737-745. [PMID: 34606933 DOI: 10.1053/j.ajkd.2021.08.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/13/2021] [Indexed: 12/13/2022]
Abstract
Hepatorenal syndrome (HRS) is a form of acute kidney injury occurring in patients with advanced cirrhosis and is associated with significant morbidity and mortality. The pathophysiology underlying HRS begins with increasing portal pressures leading to the release of vasodilatory substances which result in pooling blood in the splanchnic system and a corresponding reduction in effective circulating volume. Compensatory activation of the sympathetic nervous system, renin-angiotensin-aldosterone system and release of arginine vasopressin serve to defend mean arterial pressure but at the cost of severe constriction of the renal vasculature, leading to a progressive, often fulminant form of AKI. While there are no approved treatments for HRS in the United States, multiple countries, including much of Europe, utilize terlipressin, a synthetic vasopressin analogue, as first-line therapy. The recently published CONFIRM trial, the third randomized trial based in North America evaluating terlipressin, met its primary endpoint, showing greater rates of HRS reversal in the terlipressin arm. However, due to concerns about apparent increased rates of respiratory adverse events and a lack of evidence for mortality benefit, terlipressin was not approved by the Food and Drug Administration (FDA). In this Perspective, we explore the history of regulatory approval for terlipressin in the United States, examine the results from CONFIRM and the concerns they raised and consider the future role of terlipressin in this critical clinical area of continued unmet need.
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Affiliation(s)
- Justin M Belcher
- Department of Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, CT, USA and Section of Nephrology, VA-Connecticut Healthcare System, West Haven, CT, USA.
| | - Xavier Vela Parada
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Luis A Juncos
- Department of Medicine, University of Arkansas for Medical Sciences, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | - Nithin Karakala
- Department of Medicine, University of Arkansas for Medical Sciences, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | - Hani M Wadei
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Kevin R Regner
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, VA-Connecticut Healthcare System, West Haven, CT, USA
| | | | - Samir M Parikh
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess and Harvard Medical School, Boston, MA, USA; Division of Nephrology, UT Southwestern, Dallas, TX
| | - Raymond T Chung
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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6
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Hepatorenal syndrome: pathophysiology and evidence-based management update. ROMANIAN JOURNAL OF INTERNAL MEDICINE 2021; 59:227-261. [DOI: 10.2478/rjim-2021-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Indexed: 11/20/2022] Open
Abstract
Abstract
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.
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Rajakumar A, Appuswamy E, Kaliamoorthy I, Rela M. Renal Dysfunction in Cirrhosis: Critical Care Management. Indian J Crit Care Med 2021; 25:207-214. [PMID: 33707901 PMCID: PMC7922436 DOI: 10.5005/jp-journals-10071-23721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Cirrhotic patients with manifestations of the end-stage liver disease have a high risk for developing renal dysfunction even with minor insults. The development of renal dysfunction increases the morbidity and mortality of these patients. Causes of renal dysfunction in cirrhotics can be due to hepatorenal syndrome (HRS) or acute kidney injury (AKI) resulting from prerenal, renal, and postrenal causes. Development of pretransplant renal dysfunction has been shown to affect post-liver transplantation outcomes. Early detection and aggressive strategies for the prevention of further progression of renal dysfunction seem to decrease the morbidity and improve survival in this group of patients. This article aims to outline the pathogenesis of renal dysfunction in cirrhosis, etiological factors, and evaluation of renal dysfunction, strategies for aggressive therapy for renal dysfunction, the indications of renal replacement therapy (RRT) in this group of patients, and the various modalities of RRT with their merits and demerits. A thorough understanding of the pathogenesis, early detection, and aggressive corrective measures for AKI can prevent further progression. In conclusion, a good knowledge of treatment modalities available for renal dysfunction in cirrhosis and institution of timely interventions can significantly improve survival in this group of patients.
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Affiliation(s)
- Akila Rajakumar
- Department of Liver Anaesthesia and Intensive Care, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India
| | - Ellango Appuswamy
- Department of Liver Anaesthesia and Intensive Care, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Ilankumaran Kaliamoorthy
- Department of Liver Anaesthesia and Intensive Care, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India
| | - Mohamed Rela
- Department of Liver Transplantation and HPB Surgery, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India
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INASL-ISN Joint Position Statements on Management of Patients with Simultaneous Liver and Kidney Disease. J Clin Exp Hepatol 2021; 11:354-386. [PMID: 33994718 PMCID: PMC8103529 DOI: 10.1016/j.jceh.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/27/2020] [Indexed: 01/10/2023] Open
Abstract
Renal dysfunction is very common among patients with chronic liver disease, and concomitant liver disease can occur among patients with chronic kidney disease. The spectrum of clinical presentation and underlying etiology is wide when concomitant kidney and liver disease occur in the same patient. Management of these patients with dual onslaught is challenging and requires a team approach of hepatologists and nephrologists. No recent guidelines exist on algorithmic approach toward diagnosis and management of these challenging patients. The Indian National Association for Study of Liver (INASL) in association with Indian Society of Nephrology (ISN) endeavored to develop joint guidelines on diagnosis and management of patients who have simultaneous liver and kidney disease. For generating these guidelines, an INASL-ISN Taskforce was constituted, which had members from both the societies. The taskforce first identified contentious issues on various aspects of simultaneous liver and kidney diseases, which were allotted to individual members of the taskforce who reviewed them in detail. A round-table meeting of the Taskforce was held on 20-21 October 2018 at New Delhi to discuss, debate, and finalize the consensus statements. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications. The strength of recommendations (strong and weak) thus reflects the quality (grade) of underlying evidence (I, II, III). We present here the INASL-ISN Joint Position Statements on Management of Patients with Simultaneous Liver and Kidney Disease.
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Saxena R, Anand A, Deep A. Use of terlipressin in critically ill children with liver disease. BMC Nephrol 2020; 21:360. [PMID: 32819297 PMCID: PMC7441708 DOI: 10.1186/s12882-020-01914-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 06/26/2020] [Indexed: 01/25/2023] Open
Abstract
Background Terlipressin, a long-acting synthetic analogue of vasopressin has been used in the adult population for various indications including hepatorenal syndrome (HRS-AKI), esophageal variceal hemorrhage (EVH) and shock, but its use in pediatrics is still limited to individualized cases and data on safety and efficacy is scant. Methods We reviewed the patient records of children with liver disease and Acute Kidney Injury requiring terlipressin admitted to the Paediatric Intensive Care Unit (PICU) of King’s College Hospital, London from January 2010–December 2017, with special emphasis on its effect on renal parameters and adverse event profile. Results Twenty-one terlipressin administration records in a total of 16 patients (median) (IQR) 10 years (6.1–14.4) were included. The drug was initially given as a bolus dose in all cases, followed by either bolus or infusion with median dosage being 5.2 (3.8–6.7) mcg/kg/hour. After administration, a sustained increase of mean arterial pressure was observed. There was an improvement in serum creatinine (Cr) (at 24 h; p = 0.386) and increase in urine output (UO), especially in the hepatorenal syndrome subgroup (HRS-AKI). We found minimal evidence of gastrointestinal side effects including feeding intolerance and vasoconstrictive side effects including cyanosis / ischaemia of extremities. Conclusion Terlipressin was found to be safe in critically sick children with liver disease with positive impact on renal parameters which might be taken as a surrogate marker of HRS reversal, though effects on outcomes are difficult to ascertain. It is important to be aware of all its side-effects and actively watch for them. Future prospective studies are warranted to validate these findings.
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Affiliation(s)
- Romit Saxena
- Paediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Aravind Anand
- Paediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Akash Deep
- Paediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
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Mattos ÂZ, Schacher FC, Mattos AA. Vasoconstrictors in hepatorenal syndrome - A critical review. Ann Hepatol 2020; 18:287-290. [PMID: 31023616 DOI: 10.1016/j.aohep.2018.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 12/31/2018] [Accepted: 12/31/2018] [Indexed: 02/04/2023]
Abstract
Hepatorenal syndrome has the worst prognosis among causes of acute kidney injury in cirrhotic patients. Its definitive treatment is liver transplantation. Nevertheless, considering its high short-term mortality rate and the shortage of liver grafts, a pharmacological treatment is of utmost importance, serving as a bridge to liver transplant. The clinical management of hepatorenal syndrome is currently based on the use of a vasoconstrictor in association with albumin. Terlipressin, noradrenaline and the combination of midodrine and octreotide could be used to treat hepatorenal syndrome. Among these options, terlipressin seems to gather the strongest body of evidence regarding efficacy and should be considered the first line of treatment whenever available and in the absence of contraindications. Treatment with a vasoconstrictor and albumin should be promptly initiated after the diagnosis of hepatorenal syndrome in order for patients to have higher chances of recovery.
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Affiliation(s)
- Ângelo Z Mattos
- Federal University of Health Sciences of Porto Alegre, Graduate Program in Medicine: Hepatology, Porto Alegre, Brazil; Irmandade Santa Casa de Misericórdia de Porto Alegre, Gastroenterology and Hepatology Unit, Porto Alegre, Brazil.
| | - Fernando C Schacher
- Irmandade Santa Casa de Misericórdia de Porto Alegre, Gastroenterology and Hepatology Unit, Porto Alegre, Brazil
| | - Angelo A Mattos
- Federal University of Health Sciences of Porto Alegre, Graduate Program in Medicine: Hepatology, Porto Alegre, Brazil; Irmandade Santa Casa de Misericórdia de Porto Alegre, Gastroenterology and Hepatology Unit, Porto Alegre, Brazil
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Park GC, Hwang S, Jung DH, Song GW, Ahn CS, Kim KH, Moon DB, Ha TY, Yoon YI, Cho HD, Kwon JH, Chung YK, Kang SH, Jung IJ, Choi JU, Lee SG. Is renal replacement therapy necessary in deceased donor liver transplantation candidates with hepatorenal syndrome?: a 2-year experience at a high-volume center. Ann Surg Treat Res 2020; 98:102-109. [PMID: 32051819 PMCID: PMC7002878 DOI: 10.4174/astr.2020.98.2.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/14/2019] [Accepted: 11/15/2019] [Indexed: 12/27/2022] Open
Abstract
Purpose Hepatorenal syndrome (HRS) is a fatal complication in patients with end-stage liver disease awaiting liver transplantation (LT). HRS often develops in patients with high model for end-stage liver disease (MELD) score. This study investigated the outcomes of peritransplant management of HRS in a high-volume LT center in Korea for 2 years. Methods A total of 157 recipients that deceased donor liver transplantation (DDLT) from January 2017 to December 2018 were included. In-hospital mortality (IHM) was analyzed in relation to pre- and posttransplant application of renal replacement therapy (RRT). Results Primary diagnoses for DDLT were alcoholic liver disease (n = 61), HBV-associated liver cirrhosis (n = 48), retransplantation for chronic graft failure (n = 24), and others (n = 24). Mean MELD score was 34.6 ± 6.2 with 72 patients at Korean Network for Organ Sharing MELD status 2 (45.9%), 43 at status 3 (27.4%), 36 at status 4 (22.9%), and 6 at status 5 (3.8%). Pretransplant RRT was performed in 16 patients (10.2%) that did not show IHM. Posttransplant RRT was performed in 69 patients (44.0%), for whom IHM incidence was 15.9%. In 53 patients that had undergone de novo posttransplant RRT, IHM incidence increased to 20.8%. IHM in the 88 patients not requiring RRT was 2.3%. Conclusion The majority of adult DDLT recipients in Korean MELD score-based allocation system have very high MELD scores, which is often associated with HRS. Pretransplant RRT appears to improve posttransplant survival outcomes. We thereby recommend that, if indicated, pretransplant RRT be performed while awaiting DDLT.
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Affiliation(s)
- Gil-Chun Park
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-In Yoon
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hui-Dong Cho
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Hyun Kwon
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Kyu Chung
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Hyun Kang
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - I-Ji Jung
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Uk Choi
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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12
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Facciorusso A. Hepatorenal Syndrome Type 1: Current Challenges And Future Prospects. Ther Clin Risk Manag 2019; 15:1383-1391. [PMID: 31819465 PMCID: PMC6886557 DOI: 10.2147/tcrm.s205328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/05/2019] [Indexed: 12/13/2022] Open
Abstract
Renal dysfunction represents a dreadful complication of advanced liver cirrhosis. In addition to the traditional types of acute kidney injury (AKI) that can occur in the general population, cirrhotics might experience a different kind of renal dysfunction, called hepatorenal syndrome (HRS). The exact definition of HRS is a functional renal dysfunction caused by overactivity of the endogenous vasoactive systems (in particular intrarenal circulation) which lead to reduced renal perfusion. Type I HRS (HRS-1) is characterized by an abrupt deterioration in renal function (in less than 2 weeks), defined by a doubling of baseline sCr to >2.5 mg/dL or a 50% reduction in the initial 24 hrs creatinine clearance to <20 mL/min. Frequent precipitating events leading to HRS-1 are bacterial infections, gastrointestinal hemorrhage, or large-volume paracentesis without adequate albumin administration as well as massive diuretic use. In 2015, the international club of ascites (ICA) revised the definitions and recommendations concerning HRS. The revised definition allows to adopt effective pharmacological therapy based on albumin and vasoconstrictors in an earlier stage thus not influenced anymore by a rigid sCr cut-off value as by the previous definition of HRS-1. The aim of this article was to provide an updated overview of the latest advancements in the field of hepatorenal syndrome and of the recent amendments of the previous definitions of kidney injury in cirrhotic patients.
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13
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Zhang J, Rössle M, Zhou X, Deng J, Liu L, Qi X. Terlipressin for the treatment of hepatorenal syndrome: an overview of current evidence. Curr Med Res Opin 2019; 35:859-868. [PMID: 30474439 DOI: 10.1080/03007995.2018.1552575] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatorenal syndrome (HRS) is a serious complication of liver cirrhosis, which is of pre-renal origin due to central volume depletion together with cardiac dysfunction and characterized by oliguria with severe urinary sodium retention and elevated serum creatinine levels. HRS is divided into HRS I, which is rapidly progressive and mostly seen in patients with decompensated liver cirrhosis, and HRS II, which progresses more slowly and is always accompanied by gross ascites. Liver transplantation is the best choice of treatment for HRS but rarely available. Current mainstay pharmacological therapies are vasoconstrictors, such as terlipressin, noradrenaline and dopamine, in combination with albumin. This paper aims to overview the current evidence regarding outcomes of terlipressin for the treatment of HRS.
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Affiliation(s)
- Jingqiao Zhang
- a Department of Gastroenterology , General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area) , Shenyang , China
- b Department of Pharmacology , General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Millitary Area) , Shenyang , China
- c Postgraduate College, Shenyang Pharmaceutical University , Shenyang , China
| | - Martin Rössle
- d Department of Internal Medicine II , University of Freiburg , Freiburg , Germany
| | - Xinmiao Zhou
- e Postgraduate College, Jinzhou Medical University , Jinzhou , China
| | - Jiao Deng
- b Department of Pharmacology , General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Millitary Area) , Shenyang , China
| | - Lu Liu
- f Section of Medical Service, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area) , Shenyang , China
| | - Xingshun Qi
- a Department of Gastroenterology , General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area) , Shenyang , China
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14
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Moore EM, Bellomo R, Nichol AD. The Meaning of Acute Kidney Injury and Its Relevance to Intensive Care and Anaesthesia. Anaesth Intensive Care 2019. [DOI: 10.1177/0310057x1204000604] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- E. M. Moore
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Student, Department of Epidemiology and Preventive Medicine, Monash University
| | - R. Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - A. D. Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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15
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Zhang JQ, Wu YH, Qi XS. Current evidence regarding terlipressin for treatment of hepatorenal syndrome. Shijie Huaren Xiaohua Zazhi 2019; 27:1-5. [DOI: 10.11569/wcjd.v27.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hepatorenal syndrome (HRS) is a serious complication of liver cirrhosis, which is characterized by oliguria, severe urinary sodium retention, and elevated serum creatinine levels. Liver transplantation is the best choice of therapy, but is rarely available. Current mainstay pharmacological therapy is vasoconstrictors with albumin. Terlipressin is a synthetic analog of vasopressin, and it has been used for the treatment of HRS. This article reviews the current status regarding terlipressin in the management of HRS from the perspective of evidence-based medicine.
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Affiliation(s)
- Jing-Qiao Zhang
- Shenyang Pharmaceutical University, Shenyang 110016, Liaoning Province, China
| | - Yun-Hai Wu
- Intensive Care Unit, the Sixth Hospital of Shenyang, Shenyang 110006, Liaoning Province, China
| | - Xing-Shun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110016, Liaoning Province, China
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16
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Gasteiger L, Eschertzhuber S, Tiefenthaler W. Perioperative management of liver surgery-review on pathophysiology of liver disease and liver failure. Eur Surg 2018; 50:81-86. [PMID: 29875796 PMCID: PMC5968074 DOI: 10.1007/s10353-018-0522-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 03/23/2018] [Indexed: 12/17/2022]
Abstract
An increasing number of patients present for liver surgery. Given the complex pathophysiological changes in chronic liver disease (CLD), it is pivotal to understand the fundamentals of chronic and acute liver failure. This review will give an overview on related organ dysfunction as well as recommendations for perioperative management and treatment of liver failure-related symptoms.
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Affiliation(s)
- Lukas Gasteiger
- Department of Anaesthesia and Intensive Care, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Stephan Eschertzhuber
- Department of Anaesthesia and Intensive Care, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
- Department of Anaesthesia and Intensive Care, General Hospital Hall in Tirol, Hall in Tirol, Austria
| | - Werner Tiefenthaler
- Department of Anaesthesia and Intensive Care, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
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17
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Wang H, Liu A, Bo W, Feng X, Hu Y. Terlipressin in the treatment of hepatorenal syndrome: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e0431. [PMID: 29668606 PMCID: PMC5916651 DOI: 10.1097/md.0000000000010431] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Hepatorenal syndrome is a fatal complication of advanced cirrhosis. Terlipressin is the most widely used treatment method, however, the therapy effects remain inconsonant. We aim to systematically assess the safety and efficacy of terlipressin for hepatorenal syndrome. METHODS We conducted a systematic review and meta-analysis. Randomized controlled trials involving terlipressin for hepatorenal syndrome were included in a systematic literature search. Two authors independently assessed the studies for inclusion and extracted the data. A meta-analysis was conducted to estimate the safety and efficacy of terlipressin for hepatorenal syndrome. RESULTS A total of 18 randomized controlled trials including 1011 patients were included. Hepatorenal syndrome reverse rate was 42.0% in the terlipressin group and 26.2% in the non-terlipressin group. Terlipressin had greater hepatorenal syndrome reverse rate and renal function improvement rate than placebo and octreotide in the management of HRS. Comparing to norepinephrine, terlipressin had similar efficacy, but with more adverse events. No significant difference of the efficacy was found between terlipressin and dopamine treatment. The subgroup analysis for type 1 HRS had the above same results, except that the adverse events were not significant different between norepinephrine group and terlipressin group. CONCLUSIONS Terlipressin was superior to placebo and octreotide for reversal of hepatorenal syndrome and improving renal function, but it had no superiority comparing to norepinephrine.
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18
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Abstract
BACKGROUND Hepatorenal syndrome (HRS) is a serious complication of advanced chronic liver disease. Different pharmacological therapies have variable efficacy. We performed a systematic review and meta-analysis to compare the efficacy of various drugs in the treatment of HRS. STUDY Randomized controlled trials comparing active drug with placebo or comparing 2 different drugs were included in this analysis. Primary study outcome was reversal of HRS. Secondary outcomes were HRS relapse and patient survival. Subgroup analysis was performed on patients with type 1 HRS. RESULTS Thirteen randomized controlled trial were eligible for analysis. Terlipressin plus albumin was more efficacious than placebo plus albumin (odds ratio=4.72; 95% confidence interval, 1.72-12.93; P=0.003) or midodrine plus albumin and octreotide (odds ratio=5.94; 95% confidence interval, 1.69-20.85; P=0.005), for HRS reversal. However, no significant difference was noted comparing terlipressin plus albumin versus noradrenaline plus albumin, octreotide plus albumin versus placebo plus albumin or noradrenaline plus albumin versus midodrine plus albumin and octreotide. None of the comparisons showed difference on HRS relapse or patient survival. Subgroup analysis revealed that terlipressin was more effective than placebo for type 1 HRS reversal, but no significant differences were noted between any other comparisons, and none of the comparisons showed difference on HRS relapse or patient survival. CONCLUSIONS Intravenous infusion of terlipressin is the most effective medical therapy for reversing HRS. Intravenous infusion of noradrenaline is an acceptable alternative. Studies are needed as basis for developing pharmacological strategies to reduce relapse of HRS and improve patient survival.
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19
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Song T, Rössle M, He F, Liu F, Guo X, Qi X. Transjugular intrahepatic portosystemic shunt for hepatorenal syndrome: A systematic review and meta-analysis. Dig Liver Dis 2018; 50:323-330. [PMID: 29422242 DOI: 10.1016/j.dld.2018.01.123] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/13/2017] [Accepted: 01/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hepatorenal syndrome is a severe complication of advanced liver diseases with a dismal prognosis. AIMS This systematic review and meta-analysis aims to explore the efficacy and safety of transjugular intrahepatic portosystemic shunt for the treatment of hepatorenal syndrome. METHOD Publications were searched via PubMed and EMBASE databases. The pooled proportion and mean difference were calculated by using a random-effect model. RESULTS Nine publications were included, in which 128 patients with hepatorenal syndrome were treated with transjugular intrahepatic portosystemic shunt. The pooled short-term and 1-year survival rates were 72% and 47% in type 1 hepatorenal syndrome and 86% and 64% in type 2 hepatorenal syndrome. No lethal procedure-related complications were observed. The pooled rate of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt was 49%. The pooled rate of renal function improvement after transjugular intrahepatic portosystemic shunt was 93% in type 1 hepatorenal syndrome and 83% in any type of hepatorenal syndrome. After transjugular intrahepatic portosystemic shunt, serum creatinine, blood urea nitrogen, serum sodium, sodium excretion, and urine volume were significantly improved; by comparison, serum bilirubin slightly increased, but the difference was not statistically significant. CONCLUSION Limited evidence suggested a potential survival benefit of transjugular intrahepatic portosystemic shunt in patients with hepatorenal syndrome but with a high incidence of hepatic encephalopathy.
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Affiliation(s)
- Tingxue Song
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China; Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Martin Rössle
- Department of Internal Medicine II, University of Freiburg, Freiburg, Germany
| | - Fuliang He
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Fuquan Liu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China; Postgraduate College, Liaoning University of Traditional Chinese Medicine, Shenyang, China.
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.
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20
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Mindikoglu AL, Pappas SC. New Developments in Hepatorenal Syndrome. Clin Gastroenterol Hepatol 2018; 16:162-177.e1. [PMID: 28602971 PMCID: PMC5831376 DOI: 10.1016/j.cgh.2017.05.041] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/26/2017] [Accepted: 05/28/2017] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Ayse L. Mindikoglu
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Division of Abdominal Transplantation,Baylor College of Medicine, Margaret M. and Albert B. Alkek Department of Medicine, Section of Gastroenterology and Hepatology
| | - Stephen C. Pappas
- Baylor College of Medicine, Margaret M. and Albert B. Alkek Department of Medicine, Section of Gastroenterology and Hepatology
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Zheng JN, Han YJ, Zou TT, Zhou YJ, Sun DQ, Zhong JH, Braddock M, Zheng MH. Comparative efficacy of vasoconstrictor therapies for type 1 hepatorenal syndrome: a network meta-analysis. Expert Rev Gastroenterol Hepatol 2017; 11:1009-1018. [PMID: 28708431 DOI: 10.1080/17474124.2017.1356223] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The outcome of a comparative efficacy and safety of vasoconstrictor therapies for treatment of patients with type 1 hepatorenal syndrome (HRS-1) remain inconclusive. Areas covered: We searched literature databases for randomized controlled trials (RCTs) until 31 January 2016, and included ten eligible RCTs. In conclusion, terlipressin was the most efficacious vasoconstrictor drug for HRS-1, but had a higher probability of causing AEs. Norepinephrine was an attractive alternative to terlipressin and associated with less AEs. Expert commentary: To date, most previous traditional meta-analyses included trials with a limited population and compared terlipressin alone or with albumin against no intervention or albumin. Since different HRS types have different diagnoses and show different responses to vasoconstrictors, it may be questionable to combine data from patients with type 1 and type 2 HRS, which has been reported for most previous meta-analyses. Thus, performing a high-quality network meta-analysis of the existing literature is a valuable way to interrogate published data and to draw conclusions which may inform on the best interventional strategy.
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Affiliation(s)
- Ji-Na Zheng
- a Department of Hepatology, Liver Research Center , the First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China.,b School of the First Clinical Medical Sciences , Wenzhou Medical University , Wenzhou , China
| | - Yi-Jing Han
- a Department of Hepatology, Liver Research Center , the First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China.,b School of the First Clinical Medical Sciences , Wenzhou Medical University , Wenzhou , China
| | - Tian-Tian Zou
- a Department of Hepatology, Liver Research Center , the First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China.,c School of the Second Clinical Medical Sciences , Wenzhou Medical University , Wenzhou , China
| | - Yu-Jie Zhou
- a Department of Hepatology, Liver Research Center , the First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China.,b School of the First Clinical Medical Sciences , Wenzhou Medical University , Wenzhou , China
| | - Dan-Qin Sun
- d Department of Nephrology , Affiliated Wuxi Second Hospital, Nanjing Medical University , Wuxi , China
| | - Jian-Hong Zhong
- e Department of Hepatobiliary Surgery , Affiliated Tumor Hospital of Guangxi Medical University , Nanning , China
| | - Martin Braddock
- f Global Medicines Development , AstraZeneca R&D , Loughborough , United Kingdom
| | - Ming-Hua Zheng
- a Department of Hepatology, Liver Research Center , the First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China.,g Institute of Hepatology , Wenzhou Medical University , Wenzhou , China
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Abstract
Acute kidney injury (AKI) occurs frequently in patients with liver disease and increases morbidity and mortality. Hepatorenal syndrome is a common cause of AKI in patients with decompensated cirrhosis and is due to alterations in systemic and renal hemodynamics. Serum creatinine-based estimation of kidney function is a key component of the Model for End-stage Liver Disease score in liver transplant candidates. Continuous renal replacement therapy is used in critically ill patients with liver failure and AKI. Simultaneous liver-kidney transplantation (SLK) may be required in patients with liver failure and prolonged AKI. Identification of appropriate candidates for SLK remains controversial.
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Affiliation(s)
- Kevin R Regner
- Division of Nephrology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Kai Singbartl
- Department of Anesthesiology, Milton S. Hershey Medical Center, Penn State College of Medicine, PO Box 850, H187, Hershey, PA 17033, USA.
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Allegretti AS, Israelsen M, Krag A, Jovani M, Goldin AH, Schulman AR, Winter RW, Gluud LL. Terlipressin versus placebo or no intervention for people with cirrhosis and hepatorenal syndrome. Cochrane Database Syst Rev 2017; 6:CD005162. [PMID: 29943803 PMCID: PMC6481608 DOI: 10.1002/14651858.cd005162.pub4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Hepatorenal syndrome is a potentially reversible renal failure associated with severe liver disease. The disease is relatively common among people with decompensated cirrhosis. Terlipressin is a drug that increases the blood flow to the kidneys by constricting blood vessels. The previous version of this systematic review found a potential beneficial effect of terlipressin on mortality and renal function in people with cirrhosis and hepatorenal syndrome. OBJECTIVES To assess the beneficial and harmful effects of terlipressin versus placebo/no intervention for people with cirrhosis and hepatorenal syndrome. SEARCH METHODS We identified eligible trials through searches of the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase, and Science Citation Index Expanded, and manual searches until 21 November 2016. SELECTION CRITERIA Randomised clinical trials (RCTs) involving participants with cirrhosis and type 1 or type 2 hepatorenal syndrome allocated to terlipressin versus placebo or no intervention. We allowed co-administration with albumin administered to both comparison groups. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from trial reports and undertook correspondence with the authors. Primary outcomes were mortality, hepatorenal syndrome, and serious adverse events. We conducted sensitivity analyses of RCTs in which participants received albumin, subgroup analyses of participants with type 1 or type 2 hepatorenal syndrome, and Trial Sequential Analyses to control random errors. We reported random-effects meta-analyses with risk ratios (RR) and 95% confidence intervals (CI). We assessed the risk of bias based on the Cochrane Hepato-Biliary Group domains. We graded the quality of the evidence using GRADE. MAIN RESULTS We included nine RCTs with a total of 534 participants with cirrhosis and ascites. One RCT had a low risk of bias for mortality and a high risk of bias for the remaining outcomes. All included trials had a high risk of bias for non-mortality outcomes. In total, 473 participants had type 1 hepatorenal syndrome. Seven RCTs specifically evaluated terlipressin and albumin. Terlipressin was associated with a beneficial effect on mortality when including all RCTs (RR 0.85, 95% CI 0.73 to 0.98; 534 participants; number needed to treat for an additional beneficial outcome (NNTB) 10.3 people; low-quality evidence). Trial Sequential Analysis including all RCTs also found a beneficial effect of terlipressin. Additional analyses showed a beneficial effect of terlipressin and albumin on reversal of hepatorenal syndrome (RR 0.63, 95% CI 0.48 to 0.82; 510 participants; 8 RCTs; NNTB 4 people; low-quality evidence). Terlipressin increased the risk of serious cardiovascular adverse events (RR 7.26, 95% CI 1.70 to 31.05; 234 participants; 4 RCTs), but it had no effect on the risk of serious adverse events when analysed as a composite outcome (RR 0.91, 95% CI 0.68 to 1.21; 534 participants; 9 RCTs; number needed to treat for an additional harmful outcome 24.5 people; low-quality evidence). Non-serious adverse events were mainly gastrointestinal, including diarrhoea (RR 5.76, 95% CI 2.19 to 15.15; 240 participants; low-quality evidence) and abdominal pain (RR 1.54, 95% CI 0.97 to 2.43; 294 participants; low-quality evidence).We identified one ongoing trial on terlipressin versus placebo in participants with cirrhosis, ascites, and hepatorenal syndrome type 1.Three RCTs reported funding from a pharmaceutical company. The remaining trials did not report funding or did not receive funding from pharmaceutical companies. AUTHORS' CONCLUSIONS This review suggests that terlipressin may be associated with beneficial effects on mortality and renal function in people with cirrhosis and type 1 hepatorenal syndrome, but it is also associated with serious adverse effects. We downgraded the strength of the evidence due to methodological issues including bias control, clinical heterogeneity, and imprecision. Consequently, additional evidence is needed.
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Affiliation(s)
- Andrew S Allegretti
- Massachusetts General HospitalDivision of Nephrology, Department of MedicineBostonUSAMA 02114
| | - Mads Israelsen
- Odense University HospitalDepartment of Gastroenterology and HepatologySdr. Boulevard 29Odense CDenmark5000
| | - Aleksander Krag
- Odense University HospitalDepartment of Gastroenterology and HepatologySdr. Boulevard 29Odense CDenmark5000
| | - Manol Jovani
- Massachusetts General Hospital and Harvard Medical SchoolDivision of Gastroenterology55 Fruit StBostonUSAMA 02114
| | - Alison H Goldin
- Brigham and Women's HospitalDivision of Gastroenterology, Hepatology and EndoscopyBostonUSAMA 02115
| | - Allison R Schulman
- Brigham and Women's HospitalDivision of Gastroenterology, Hepatology and EndoscopyBostonUSAMA 02115
| | - Rachel W Winter
- Brigham and Women's HospitalDivision of Gastroenterology, Hepatology and EndoscopyBostonUSAMA 02115
| | - Lise Lotte Gluud
- Copenhagen University Hospital HvidovreGastrounit, Medical DivisionKettegaards AlleHvidovreDenmark2650
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Sanyal AJ, Boyer TD, Frederick RT, Wong F, Rossaro L, Araya V, Vargas HE, Reddy KR, Pappas SC, Teuber P, Escalante S, Jamil K. 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. Aliment Pharmacol Ther 2017; 45:1390-1402. [PMID: 28370090 PMCID: PMC5434950 DOI: 10.1111/apt.14052] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 10/28/2016] [Accepted: 02/27/2017] [Indexed: 12/17/2022]
Abstract
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).
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Affiliation(s)
- A. J. Sanyal
- Department of MedicineVirginia Commonwealth UniversityRichmondVAUSA
| | - T. D. Boyer
- Department of MedicineUniversity of ArizonaTucsonAZUSA
| | - R. T. Frederick
- Department of TransplantationCalifornia Pacific Medical CenterSan FranciscoCAUSA
| | - F. Wong
- Department of MedicineUniversity of TorontoTorontoONCanada
| | - L. Rossaro
- University of California DavisSacramentoCAUSA
| | - V. Araya
- Department of Gastroenterology and HepatologyCentral Bucks Specialists, Ltd.DoylestownPAUSA
| | - H. E. Vargas
- Division of Gastroenterology and HepatologyMayo Clinic ArizonaPhoenixAZUSA
| | - K. R. Reddy
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | | | | | - S. Escalante
- Ikaria Therapeutics LLC/a Mallinckrodt CompanyHamptonNJUSA
| | - K. Jamil
- Ikaria Therapeutics LLC/a Mallinckrodt CompanyHamptonNJUSA
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He GL, Feng L, Cai L, Zhou CJ, Cheng Y, Jiang ZS, Pan MX, Gao Y. Artificial liver support in pigs with acetaminophen-induced acute liver failure. World J Gastroenterol 2017; 23:3262-3268. [PMID: 28566885 PMCID: PMC5434431 DOI: 10.3748/wjg.v23.i18.3262] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/24/2017] [Accepted: 03/20/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To establish a reversible porcine model of acute liver failure (ALF) and treat it with an artificial liver system.
METHODS Sixteen pigs weighing 30-35 kg were chosen and administered with acetaminophen (APAP) to induce ALF. ALF pigs were then randomly assigned to either an experimental group (n = 11), in which a treatment procedure was performed, or a control group (n = 5). Treatment was started 20 h after APAP administration and continued for 8 h. Clinical manifestations of all animals, including liver and kidney functions, serum biochemical parameters and survival times were analyzed.
RESULTS Twenty hours after APAP administration, the levels of serum aspartate aminotransferase, total bilirubin, creatinine and ammonia were significantly increased, while albumin levels were decreased (P < 0.05). Prothrombin time was found to be extended with progression of ALF. After continuous treatment for 8 h (at 28 h), aspartate aminotransferase, total bilirubin, creatinine, and ammonia showed a decrease in comparison with the control group (P < 0.05). A cross-section of livers revealed signs of vacuolar degeneration, nuclear fragmentation and dissolution. Concerning survival, porcine models in the treatment group survived for longer times with artificial liver system treatment (P < 0.05).
CONCLUSION This model is reproducible and allows for quantitative evaluation of new liver systems, such as a bioartificial liver. The artificial liver system (ZHJ-3) is safe and effective for the APAP-induced porcine ALF model.
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Use of Terlipressin in an Elderly Patient With Moderate Aortic Valve Stenosis Accompanied by Episodic Atrial Fibrillation During Liver Transplantation: A Case Report. Transplant Proc 2016; 48:3203-3206. [PMID: 27932181 DOI: 10.1016/j.transproceed.2016.02.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 02/05/2016] [Indexed: 10/20/2022]
Abstract
Anesthesia for patients with moderate aortic stenosis accompanied by atrial fibrillation during high-risk surgery such as liver transplantation remains a challenge in maintaining control of heart rate and maintenance of cardiac output. The action of terlipressin on vasopressin receptors (mainly V1 receptors) leads to splanchnic vasoconstriction and is the key mechanism responsible for increasing systemic vascular resistance and reducing heart rate. We report successful anesthetic management using low-dose terlipressin infusion in an elderly patient who had moderate aortic stenosis with atrial fibrillation during urgent deceased-donor liver transplantation.
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27
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Cheng XS, Tan JC, Kim WR. Management of renal failure in end-stage liver disease: A critical appraisal. Liver Transpl 2016; 22:1710-1719. [PMID: 27875032 DOI: 10.1002/lt.24609] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 08/09/2016] [Indexed: 01/13/2023]
Abstract
Renal failure is a late consequence of end-stage liver disease (ESLD). Even with liver transplantation, pretransplant renal impairment remains a strong predictor of posttransplant mortality. This review seeks to summarize and critically appraise common therapies used in this setting, including pharmacologic agents, procedures (transjugular intrahepatic portosystemic shunt, renal replacement therapy), and simultaneous liver-kidney transplantation. More experimental extracorporal modalities, eg, albumin dialysis or bioartificial livers, will not be discussed. A brief discussion on the definition and pathophysiologic underpinnings of renal failure in ESLD will be held at the beginning to lay the groundwork for the main section. Liver Transplantation 22 1710-1719 2016 AASLD.
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Affiliation(s)
| | - Jane C Tan
- Division of Nephrology, Stanford University, Palo Alto, CA
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
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Arab JP, Claro JC, Arancibia JP, Contreras J, Gómez F, Muñoz C, Nazal L, Roessler E, Wolff R, Arrese M, Benítez C. Therapeutic alternatives for the treatment of type 1 hepatorenal syndrome: A Delphi technique-based consensus. World J Hepatol 2016; 8:1075-1086. [PMID: 27660674 PMCID: PMC5026999 DOI: 10.4254/wjh.v8.i25.1075] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 07/07/2016] [Accepted: 08/01/2016] [Indexed: 02/06/2023] Open
Abstract
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.
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Modi RM, Patel N, Metwally SN, Mumtaz K. Outcomes of liver transplantation in patients with hepatorenal syndrome. World J Hepatol 2016; 8:999-1011. [PMID: 27648152 PMCID: PMC5002501 DOI: 10.4254/wjh.v8.i24.999] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/20/2016] [Accepted: 07/18/2016] [Indexed: 02/06/2023] Open
Abstract
Hepatorenal syndrome (HRS) plays an important role in patients with liver cirrhosis on the wait list for liver transplantation (LT). The 1 and 5-year probability of developing HRS in cirrhotic with ascites is 20% and 40%, respectively. In this article, we reviewed current concepts in HRS pathophysiology, guidelines for HRS diagnosis, effective treatment options presently available, and controversies surrounding liver alone vs simultaneous liver kidney transplant (SLKT) in transplant candidates. Many treatment options including albumin, vasoconstrictors, renal replacement therapy, and eventual LT have remained a mainstay in the treatment of HRS. Unfortunately, even after aggressive measures such as terlipressin use, the rate of recovery is less than 50% of patients. Moreover, current SLKT guidelines include: (1) estimation of glomerular filtration rate of 30 mL/min or less for 4-8 wk; (2) proteinuria > 2 g/d; or (3) biopsy proven interstitial fibrosis or glomerulosclerosis. Even with these updated criteria there is a lack of consistency regarding long-term benefits for SLKT vs LT alone. Finally, in regards to kidney dysfunction in the post-transplant setting, an estimation of glomerular filtration rate < 60 mL/min per 1.73 m2 may be associated with an increased risk of patients having long-term end stage renal disease. HRS is common in patients with cirrhosis and those on liver transplant waitlist. Prompt identification and therapy initiation in transplant candidates with HRS may improve post-transplantation outcomes. Future studies identifying optimal vasoconstrictor regimens, alternative therapies, and factors predictive of response to therapy are needed. The appropriate use of SLKT in patients with HRS remains controversial and requires further evidence by the transplant community.
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Evidence-based clinical practice guidelines for liver cirrhosis 2015. J Gastroenterol 2016; 51:629-50. [PMID: 27246107 DOI: 10.1007/s00535-016-1216-y] [Citation(s) in RCA: 220] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 04/12/2016] [Indexed: 02/04/2023]
Abstract
The Japanese Society of Gastroenterology revised the evidence-based clinical practice guidelines for liver cirrhosis in 2015. Eighty-three clinical questions were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. Manual searching of the latest important literature was added until August 2015. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This digest version in English introduces selected clinical questions and statements related to the management of liver cirrhosis and its complications. Branched-chain amino acids relieve hypoalbuminemia and hepatic encephalopathy and improve quality of life. Nucleoside analogues and peginterferon plus ribavirin combination therapy improve the prognosis of patients with hepatitis B virus related liver cirrhosis and hepatitis C related compensated liver cirrhosis, respectively, although the latter therapy may be replaced by direct-acting antivirals. For liver cirrhosis caused by primary biliary cirrhosis and active autoimmune hepatitis, urosodeoxycholic acid and steroid are recommended, respectively. The most adequate modalities for the management of variceal bleeding are the endoscopic injection sclerotherapy for esophageal varices and the balloon-occluded retrograde transvenous obliteration following endoscopic obturation with cyanoacrylate for gastric varices. Beta-blockers are useful for primary prophylaxis of esophageal variceal bleeding. The V2 receptor antagonist tolvaptan is a useful add-on therapy in careful diuretic therapy for ascites. Albumin infusion is useful for the prevention of paracentesis-induced circulatory disturbance and renal failure. In addition to disaccharides, the nonabsorbable antibiotic rifaximin is useful for the management of encephalopathy. Anticoagulation therapy is proposed for patients with acute-onset or progressive portal vein thrombosis.
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Boyer TD, Sanyal AJ, Wong F, Frederick RT, Lake JR, O'Leary JG, Ganger D, Jamil K, Pappas SC. Terlipressin Plus Albumin Is More Effective Than Albumin Alone in Improving Renal Function in Patients With Cirrhosis and Hepatorenal Syndrome Type 1. Gastroenterology 2016; 150:1579-1589.e2. [PMID: 26896734 DOI: 10.1053/j.gastro.2016.02.026] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 02/09/2016] [Accepted: 02/10/2016] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Thomas D Boyer
- Department of Medicine, University of Arizona, Tucson, Arizona.
| | - Arun J Sanyal
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - R Todd Frederick
- Department of Medicine, California Pacific Medical Center, San Francisco, California
| | - John R Lake
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | | | - Daniel Ganger
- Department of Medicine, Northwestern University, Chicago, Illinois
| | - Khurram Jamil
- Ikaria Therapeutics, LLC, a Mallinckrodt Company, Hampton, New Jersey
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Turk T, Al Saadi T, Sawaf B, Alkhatib M, Zakaria MI, Daaboul B. Progressive liver failure post acute hepatitis A, over a three-month period, resulting in hepatorenal syndrome and death. Gastroenterol Rep (Oxf) 2016; 5:161-164. [PMID: 27247182 PMCID: PMC5421466 DOI: 10.1093/gastro/gow009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 02/29/2016] [Indexed: 11/25/2022] Open
Abstract
Hepatitis A is a common viral illness worldwide. It usually results in an acute, self-limiting disease and only rarely leads to fulminant hepatic failure or any other complications. During the period of conflict in Syria, and due to the damages to water infrastructure and poor sanitation, a dramatic increase in hepatitis A virus infection has been documented. Here we report a rare case of a 14-year-old male whose hepatitis A was complicated with hepatorenal syndrome and subacute liver failure. The war condition in Syria impeded transportation of the patient to a nearby country for liver transplantation, contributing to his unfortunate death.
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Affiliation(s)
- Tarek Turk
- Faculty of Medicine, University of Damascus, Damascus, Syrian Arab Republic
| | - Tareq Al Saadi
- Faculty of Medicine, University of Damascus, Damascus, Syrian Arab Republic
| | - Bisher Sawaf
- Faculty of Medicine, Syrian Private University, Damascus, Syrian Arab Republic
| | - Mahmoud Alkhatib
- Faculty of Medicine, University of Damascus, Damascus, Syrian Arab Republic
| | - Mhd Ismael Zakaria
- Faculty of Medicine, Syrian Private University, Damascus, Syrian Arab Republic
| | - Bisher Daaboul
- Gastroenterology and Hepatology, Medical Care Center, Damascus, Syrian Arab Republic
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Cross-Sectional Guidelines for Therapy with Blood Components and Plasma Derivatives: Chapter 5 Human Albumin - Revised. Transfus Med Hemother 2016; 43:223-32. [PMID: 27403094 PMCID: PMC4924448 DOI: 10.1159/000446043] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 01/12/2016] [Indexed: 12/21/2022] Open
Abstract
Chapter 5 'Human Albumin' that was suspended on January 10, 2011 has been completed and updated in the present version.
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Terlipressin versus noradrenaline in the treatment of hepatorenal syndrome: systematic review with meta-analysis and full economic evaluation. Eur J Gastroenterol Hepatol 2016; 28:345-51. [PMID: 26649801 DOI: 10.1097/meg.0000000000000537] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to compare the efficacy and costs of terlipressin and noradrenaline for the treatment of hepatorenal syndrome from the perspective of the Brazilian public health system and that of a major private health insurance. METHODS Comparison of efficacy was performed through a systematic review with a meta-analysis of randomized-controlled trials using a random-effects model. Economic evaluation was carried out through cost minimization. RESULTS Four studies (154 patients) were included in the meta-analysis. There was no evidence of a difference between treatments with terlipressin or noradrenaline in terms of 30-day survival (risk ratio=1.04, 95% confidence interval=0.84-1.30, P=0.70). From the perspective of the public health system, costs of the treatments with terlipressin or noradrenaline were Int$7437.04 and Int$8406.41, respectively. From the perspective of the private health insurance, costs of treatments with terlipressin and noradrenaline were Int$13,484.57 and Int$15,061.01, respectively. CONCLUSION There was no evidence of superiority between treatment strategies using terlipressin or noradrenaline in terms of the survival of patients with hepatorenal syndrome, but the strategy using terlipressin was more economical under two different perspectives.
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Kim HY, Kim CW, Choi JY, Lee CD, Lee SH, Kim MY, Jang BK, Woo HY. Complications Requiring Hospital Admission and Causes of In-Hospital Death over Time in Alcoholic and Nonalcoholic Cirrhosis Patients. Gut Liver 2016; 10:95-100. [PMID: 26087788 PMCID: PMC4694740 DOI: 10.5009/gnl14363] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 12/19/2014] [Accepted: 01/20/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND/AIMS Data on the epidemiology of alcoholic cirrhosis, especially in Asian countries, are limited. We compared the temporal evolution of patterns of alcoholic and nonalcoholic cirrhosis over the last decade. METHODS We retrospectively examined the inpatient datasets of five referral centers during 2002 and 2011. The study included patients who were admitted due to specific complications of liver cirrhosis. We compared the causes of hospital admissions and in-hospital deaths between patients with alcoholic and nonalcoholic cirrhosis. RESULTS Among the included 2,799 hospitalizations (2,165 patients), 1,496 (1,143 patients) were from 2002, and 1,303 (1,022 patients) were from 2011. Over time, there was a reduction in the rate of hepatic encephalopathy (HE) as a cause of hospitalization and an increase in the rate of hepatocellular carcinoma. Deaths that were attributable to HE or spontaneous bacterial peritonitis (SBP) significantly decreased, whereas those due to hepatorenal syndrome (HRS) significantly increased over time in patients with alcoholic cirrhosis. However, in patients with nonalcoholic cirrhosis, hepatic failure and HRS remained the principal causes of in-hospital death during both time periods. CONCLUSIONS The major causes of in-hospital deaths have evolved from acute cirrhotic complications, including HE or SBP to HRS in alcoholic cirrhosis, whereas those have remained unchanged in nonalcoholic cirrhosis during the last decade.
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Affiliation(s)
- Hee Yeon Kim
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul,
Korea
| | - Chang Wook Kim
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul,
Korea
| | - Jong Young Choi
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul,
Korea
| | - Chang Don Lee
- Department of Internal Medicine, International St. Mary’s Hospital, Incheon,
Korea
| | - Sae Hwan Lee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan,
Korea
| | - Moon Young Kim
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju,
Korea
| | - Byoung Kuk Jang
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu,
Korea
| | - Hyun Young Woo
- Department of Internal Medicine, Pusan National University College of Medicine, Busan,
Korea
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Erly B, Carey WD, Kapoor B, McKinney JM, Tam M, Wang W. Hepatorenal Syndrome: A Review of Pathophysiology and Current Treatment Options. Semin Intervent Radiol 2015; 32:445-54. [PMID: 26622108 PMCID: PMC4640915 DOI: 10.1055/s-0035-1564794] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Brian Erly
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - William D. Carey
- Department of Gastroenterology, Cleveland Clinic, Cleveland, Ohio
| | - Baljendra Kapoor
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Mathew Tam
- Department of Radiology, Southend University Hospital, Essex, United Kingdom
| | - Weiping Wang
- Department of Radiology, Mayo Clinic, Jacksonville, Florida
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Salerno F, Navickis RJ, Wilkes MM. Albumin treatment regimen for type 1 hepatorenal syndrome: a dose-response meta-analysis. BMC Gastroenterol 2015; 15:167. [PMID: 26606982 PMCID: PMC4660686 DOI: 10.1186/s12876-015-0389-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 10/31/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Recommended treatment for type 1 hepatorenal syndrome consists of albumin and vasoconstrictor. The optimal albumin dose remains poorly characterized. This meta-analysis aimed to determine the impact of albumin dose on treatment outcomes. METHODS Clinical studies of type 1 hepatorenal syndrome treatment with albumin and vasoconstrictor were sought. Search terms included: hepatorenal syndrome; albumin; vasoconstrictor; terlipressin; midodrine; octreotide; noradrenaline; and norepinephrine. A meta-analysis was performed of hepatorenal syndrome reversal and survival in relation to albumin dose. RESULTS Nineteen clinical studies with 574 total patients were included, comprising 8 randomized controlled trials, 8 prospective studies and 3 retrospective studies. The pooled percentage of patients achieving hepatorenal syndrome reversal was 49.5% (95% confidence interval, 40.0-59.1%). Increments of 100 g in cumulative albumin dose were accompanied by significantly increased survival (hazard ratio, 1.15; 95% confidence interval, 1.02-1.31; p = 0.023). A non-significant increase of similar magnitude in hepatorenal syndrome reversal was also observed (odds ratio, 1.15; 95% confidence interval, 0.97-1.37; p = 0.10). Expected survival rates at 30 days among patients receiving cumulative albumin doses of 200, 400 and 600 g were 43.2% (95% confidence interval, 36.4-51.3%), 51.4% (95% confidence interval, 46.3-57.1%) and 59.0% (95% confidence interval, 51.9-67.2), respectively. Neither survival nor hepatorenal syndrome reversal was significantly affected by vasoconstrictor dose or type, treatment duration, age, baseline serum creatinine, bilirubin or albumin, baseline mean arterial pressure, or study design, size or time period. CONCLUSIONS This meta-analysis suggests a dose-response relationship between infused albumin and survival in patients with type 1 hepatorenal syndrome. The meta-analysis provides the best current evidence on the potential role of albumin dose selection in improving outcomes of treatment for type 1 HRS and furnishes guidance for the design of future dose-ranging studies.
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Affiliation(s)
- Francesco Salerno
- Dipartimento di Medicina Interna, Università degli Studi di Milano, Policlinico IRCCS San Donato, Via Morandi 30, 20097, Milano, Italy.
| | - Roberta J Navickis
- Hygeia Associates, 17988 Brewer Rd., Grass Valley, California, 95949, USA.
| | - Mahlon M Wilkes
- Hygeia Associates, 17988 Brewer Rd., Grass Valley, California, 95949, USA.
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Sobhonslidsuk A. Current position of vasoconstrictor and albumin infusion for type 1 hepatorenal syndrome. World J Gastrointest Pharmacol Ther 2015; 6:28-31. [PMID: 26261732 PMCID: PMC4526839 DOI: 10.4292/wjgpt.v6.i3.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 06/11/2015] [Accepted: 07/23/2015] [Indexed: 02/06/2023] Open
Abstract
Spontaneous bacterial peritonitis (SBP), refractory ascites, hepatorenal syndrome (HRS), hyponatremia and hepatic encephalopathy are complications which frequently happen during a clinical course of decompensated cirrhosis. Splanchnic and peripheral vasodilatation, increased intrarenal vasoconstriction and impaired cardiac responsive function are pathological changes causing systemic and hemodynamic derangement. Extreme renal vasoconstriction leads to severe reduction of renal blood flow and glomerular filtration rate, which finally evolves into the clinical feature of HRS. Clinical manifestations of type 1 and type 2 HRS come to medical attention differently. Patients with type 1 HRS present as acute kidney injury whereas those with type 2 HRS will have refractory ascites as the leading problem. Prompt diagnosis of type 1 HRS can halt the progression of HRS to acute tubular necrosis if the combined treatment of albumin infusion and vasoconstrictors is started timely. HRS reversal was seen in 34%-60% of patients, followed with decreasing mortality. Baseline serum levels of creatinine less than 5 mg/dL, bilirubin less than 10 mg/dL, and increased mean arterial pressure of over 5 mmHg by day 3 of the combined treatment of vasoconstrictor and albumin are the predictors of good response. Type 1 HRS can be prevented in some conditions such as albumin infusion in SBP, prophylactic antibiotics for upper gastrointestinal hemorrhage, albumin replacement after large volume paracentesis in cirrhotic patients with massive ascites. The benefit of albumin infusion in infection with primary source other than SBP requires more studies.
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Won Y, Kim H, Lim B, Ahn H, Hwang M, Lee I. Effect of Perioperative Terlipressin on Postoperative Renal Function in Patients Who Have Undergone Living Donor Liver Transplantation: A Meta-Analysis of Randomized Controlled Trials. Transplant Proc 2015; 47:1917-25. [DOI: 10.1016/j.transproceed.2015.06.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 04/13/2015] [Accepted: 06/16/2015] [Indexed: 02/06/2023]
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Huang Z, Lin C, Fang J, Wang N, Zhou R, Pan C. Acute kidney injury in hepatitis B-related acute-on-chronic liver failure without preexisting liver cirrhosis. Hepatol Int 2015; 9:416-23. [DOI: 10.1007/s12072-015-9636-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 05/04/2015] [Indexed: 12/30/2022]
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Londoño MC, Abraldes JG, Altamirano J, Decaens T, Forns X. Clinical trial watch: reports from the AASLD Liver Meeting®, Boston, November 2014. J Hepatol 2015; 62:1196-203. [PMID: 25646885 DOI: 10.1016/j.jhep.2015.01.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/22/2015] [Accepted: 01/23/2015] [Indexed: 12/26/2022]
Abstract
The late and fast developments in the field of viral hepatitis were highly expected in the 2014 AASLD Liver Meeting®. Several combinations using direct acting antivirals (DAAs) showed high rates of sustained virological response (∼95%). Importantly, high cure rates were also demonstrated in patients with previous treatment failures, decompensated cirrhosis and hepatitis C recurrence after transplantation, making it clear that the interferon era is over (not so clear for ribavirin, which might still have a role in difficult-to-treat populations). Importantly, sustained virological response was associated with an improvement in liver function (MELD and Child-Pugh scores) in patients with advanced liver disease. In the field of liver cirrhosis, there were relevant data assessing the optimal empirical antibiotic therapy in patients with spontaneous bacterial peritonitis and high risk of resistant bacteria, as well as studies evaluating the role of terlipressin in type I hepatorenal syndrome and in septic shock. Regarding hepatic encephalopathy, two randomized trials suggest that the manipulation of the microbioma in patients with cirrhosis may have a role in the management of this complication. Some novel data on NASH support the beneficial effect of bariatric surgery (after failure of lifestyle intervention) in morbid obese patients with such diagnosis: clinical and histological improvements after surgery were evident in most patients with sufficient follow-up. A few controlled studies focused on the treatment of severe acute alcoholic hepatitis. Finally, several studies on hepatocellular carcinoma (HCC) were presented, covering topics such as ultrasound screening in cirrhosis, cryoablation treatment of early HCC and the relevance of downstaging in patients with HCC awaiting liver transplantation.
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Affiliation(s)
- María-Carlota Londoño
- Liver Unit, Hospital Clínic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Juan G Abraldes
- Cirrhosis Care Clinic (CCC), Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - José Altamirano
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Vall d'Hebrón Institut de Recerca (VHIR), Barcelona, Spain
| | - Thomas Decaens
- Universités de Grenoble, CHU de Grenoble, Pôle DIGI-DUNE, Service d'Hépatologie et de Gastroentérologie, INSERM U823, Institut Albert Bonniot, Grenoble, France
| | - Xavier Forns
- Liver Unit, Hospital Clínic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain.
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Pipili C, Cholongitas E. Renal dysfunction in patients with cirrhosis: Where do we stand? World J Gastrointest Pharmacol Ther 2014; 5:156-168. [PMID: 25133044 PMCID: PMC4133441 DOI: 10.4292/wjgpt.v5.i3.156] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 02/08/2014] [Accepted: 05/08/2014] [Indexed: 02/06/2023] Open
Abstract
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.
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Terlipressin and albumin for type-1 hepatorenal syndrome associated with sepsis. J Hepatol 2014; 60:955-61. [PMID: 24447876 DOI: 10.1016/j.jhep.2013.12.032] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 11/25/2013] [Accepted: 12/22/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Terlipressin and albumin is the standard of care for classical type-1 hepatorenal syndrome (HRS) not associated with active infections. However, there is no information on efficacy and safety of this treatment in patients with type-1 HRS associated with sepsis. Study aim was to investigate the effects of early treatment with terlipressin and albumin on circulatory and kidney function in patients with type-1 HRS and sepsis and assess factors predictive of response to therapy. METHODS Prospective study in 18 consecutive patients with type-1 HRS associated with sepsis. RESULTS Treatment was associated with marked improvement in arterial pressure and suppression of the high levels of plasma renin activity and norepinephrine. Response to therapy (serum creatinine <1.5mg/dl) was achieved in 12/18 patients (67%) and was associated with improved 3-month survival compared to patients without response. Non-responders had significantly lower baseline heart rate, poor liver function tests, slightly higher serum creatinine, and higher Child-Pugh and MELD scores compared to responders. Interestingly, non-responders had higher values of CLIF-SOFA score compared to responders (14±3 vs. 8±1, respectively p<0.001), indicating greater severity of acute-on-chronic liver failure (ACLF). A CLIF-SOFA score ⩾11 had 92% sensitivity and 100% specificity in predicting no response to therapy. No significant differences were observed between responders and non-responders in baseline urinary kidney biomarkers. Treatment was safe and no patient required withdrawal of terlipressin. CONCLUSIONS Early treatment with terlipressin and albumin in patients with type-1 HRS associated with sepsis is effective and safe. Patients with associated severe ACLF are unlikely to respond to treatment.
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Fabrizi F, Aghemo A, Messa P. Hepatorenal syndrome and novel advances in its management. Kidney Blood Press Res 2013; 37:588-601. [PMID: 24356549 DOI: 10.1159/000355739] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2013] [Indexed: 12/30/2022] Open
Abstract
Hepatorenal syndrome is a complication of end stage liver disease. It is a unique form of functional renal failure related to kidney vasoconstriction in the absence of underlying kidney pathology. Hepatorenal syndrome is classified into 2 types: type-1 HRS shows a rapid and progressive decline in renal function with a very poor prognosis (median survival of about 2 weeks); type-2 HRS has a more stable kidney failure, with a median survival of 6 months; its main clinical manifestation is refractory ascites. The most appropriate therapy for HRS is liver transplantation but only a minority of HRS patients undergo the procedure due to the high mortality; survival among liver transplant recipients is lower in HRS than among their counterparts without HRS. A large body of evidence, based on observational studies and randomized controlled trials, has been accumulated in the last decade showing that terlipressin represents a milestone in the management of HRS. According to our meta-analysis of randomized trials comparing terlipressin vs. placebo (five trials, n=243 patients), the pooled rate of patients who reversed HRS by terlipressin was 8.09 (95% CI, 3.52; 18.59) (P<0.001). Among vasoconstrictors, terlipressin (a V1 vasopressin agonist) is the most widely used; however, noradrenaline is another good choice. Vasoconstrictor drugs alone or with albumin reduce mortality compared with no intervention or albumin (RR of mortality, 0.82; 95% Confidence Intervals, 0.70; 0.96) (P<0.01). Two series of patients with HRS recurrence after the first treatment have recently shown that long-term therapy with terlipressin and albumin is beneficial as a bridge to liver transplant. Nevertheless, recovery of renal function can be achieved in less than 50% of patients with HRS after terlipressin use and the recovery of renal function may also be partial in patients who are defined full responders. Renal replacement therapy should not be considered a first-line therapy for HRS Clinical trials are under way in order to assess efficacy and safety of novel therapeutic agents for the treatment of type-1 and type-2 HRS.
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Affiliation(s)
- Fabrizio Fabrizi
- Division of Nephrology, Maggiore Hospital and IRCCS Foundation, Milano, Italy
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Landoni G, Bove T, Székely A, Comis M, Rodseth RN, Pasero D, Ponschab M, Mucchetti M, Bove T, Azzolini ML, Caramelli F, Paternoster G, Pala G, Cabrini L, Amitrano D, Borghi G, Capasso A, Cariello C, Carpanese A, Feltracco P, Gottin L, Lobreglio R, Mattioli L, Monaco F, Morgese F, Musu M, Pasin L, Pisano A, Roasio A, Russo G, Slaviero G, Villari N, Vittorio A, Zucchetti M, Guarracino F, Morelli A, De Santis V, Del Sarto PA, Corcione A, Ranieri M, Finco G, Zangrillo A, Bellomo R. Reducing mortality in acute kidney injury patients: systematic review and international web-based survey. J Cardiothorac Vasc Anesth 2013; 27:1384-98. [PMID: 24103711 DOI: 10.1053/j.jvca.2013.06.028] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To identify all interventions that increase or reduce mortality in patients with acute kidney injury (AKI) and to establish the agreement between stated beliefs and actual practice in this setting. DESIGN AND SETTING Systematic literature review and international web-based survey. PARTICIPANTS More than 300 physicians from 62 countries. INTERVENTIONS Several databases, including MEDLINE/PubMed, were searched with no time limits (updated February 14, 2012) to identify all the drugs/techniques/strategies that fulfilled all the following criteria: (a) published in a peer-reviewed journal, (b) dealing with critically ill adult patients with or at risk for acute kidney injury, and (c) reporting a statistically significant reduction or increase in mortality. MEASUREMENTS AND MAIN RESULTS Of the 18 identified interventions, 15 reduced mortality and 3 increased mortality. Perioperative hemodynamic optimization, albumin in cirrhotic patients, terlipressin for hepatorenal syndrome type 1, human immunoglobulin, peri-angiography hemofiltration, fenoldopam, plasma exchange in multiple-myeloma-associated AKI, increased intensity of renal replacement therapy (RRT), CVVH in severely burned patients, vasopressin in septic shock, furosemide by continuous infusion, citrate in continuous RRT, N-acetylcysteine, continuous and early RRT might reduce mortality in critically ill patients with or at risk for AKI; positive fluid balance, hydroxyethyl starch and loop diuretics might increase mortality in critically ill patients with or at risk for AKI. Web-based opinion differed from consensus opinion for 30% of interventions and self-reported practice for 3 interventions. CONCLUSION The authors identified all interventions with at least 1 study suggesting a significant effect on mortality in patients with or at risk of AKI and found that there is discordance between participant stated beliefs and actual practice regarding these topics.
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Affiliation(s)
- Giovanni Landoni
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy.
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[Management of decompensated liver cirrhosis in the intensive care unit]. Med Klin Intensivmed Notfmed 2013; 108:646-56. [PMID: 24030843 DOI: 10.1007/s00063-013-0259-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 08/20/2013] [Indexed: 12/11/2022]
Abstract
Liver cirrhosis is the end-stage of long-standing chronic liver diseases. The occurrence of complications from liver cirrhosis increases the mortality risk, but the prognosis can be improved by optimal management in the intensive care unit (ICU). Defined diagnostic algorithms allow the etiology and presence of typical complications upon presentation to the ICU to be identified. Acute variceal bleeding requires endoscopic intervention, vasoactive drugs, antibiotics, supportive intensive care measures and, where necessary, urgent transjugular intrahepatic portosystemic shunt (TIPS) procedure. Spontaneous bacterial peritonitis needs to be diagnosed and immediately treated in patients with ascites. Hepatorenal syndrome should be treated by albumin and terlipressin. In case of respiratory failure, differential diagnosis should not only consider pneumonia, pulmonary embolism and cardiac failure, but also hepatic hydrothorax, portopulmonary hypertension and hepatopulmonary syndrome. The feasibility of liver transplantation should be always discussed in patients with decompensated cirrhosis. Artificial liver support devices may only serve as a bridging procedure until transplant.
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Abstract
Acute kidney injury (AKI) is a relatively frequent problem, occurring in approximately 20 % of hospitalized patients with cirrhosis. Although serum creatinine (S Cr) is the most commonly used method to determine AKI because of easy availability and low cost, practically it underestimates the extent of kidney injury in patients with chronic liver disease. AKI is defined as an abrupt rise in S Cr of 0.3 mg/dl or more (>26.4 mmol/l) or an increase of 150 % or more (1.5-fold) from baseline. The cause of AKI in cirrhosis is multifactorial and is unique in terms of pathogenesis. The most common causes of AKI in cirrhosis can be subdivided into either functional or structural. The functional group includes volume-responsive (prerenal azotemia) and volume-unresponsive states (hepatorenal syndrome). Volume responsive is the most common type of AKI due to frequent use of diuretics, large volume abdominal paracentesis and gastrointestinal bleeding in patients with liver disease. The structural causes include acute tubular necrosis, tubulointerstitial and glomerular diseases. Patients with decompensated cirrhosis are in a vasodilatory state leading to a decrease in effective arterial blood volume, predisposing to AKI. Therefore, management of AKI depends on the underlying cause, and therapy should be directed toward removal of the cause. The outcome in cirrhosis when patients are on dialysis is very dismal. Every effort should be made to prevent AKI.
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[Hepatorenal syndrome: focus]. Nephrol Ther 2013; 9:471-80. [PMID: 23850001 DOI: 10.1016/j.nephro.2013.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Revised: 04/25/2013] [Accepted: 05/02/2013] [Indexed: 01/10/2023]
Abstract
Hepatorenal syndrome (HRS) is a severe complication of cirrhosis. It develops as a result of abnormal hemodynamics, leading to systemic vasodilatation and renal vasoconstriction. Increased bacterial translocation, various cytokines and systemic inflammatory response system contribute to splanchnic vasodilatation, and altered renal autoregulation. An inadequate cardiac output with systolic incompetence increases the risk of renal failure. Type 1 HRS is usually initiated by a precipitating event associated with an exaggerated systemic inflammatory response, resulting in multiorgan failure. Vasoconstrictors are the basic treatment in patients with type 1 HRS; terlipressin is the superior agent. Norepinephrine can be used as an alternative. Transjugular intrahepatic portosystemic stent shunt may be applicable in a small number of patients with type 1 HRS and in most patients with type 2 HRS. Liver transplantation is the definitive treatment for HRS. The decision to do simultaneous or sequential liver and kidney transplant remains controversial. In general, patients who need more than 8 to 12 weeks of pretransplant dialysis should be considered for combined liver-kidney transplantation.
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