Advances in management of hepatorenal syndrome.
01 Sep 2021-Current Opinion in Nephrology and Hypertension (Ovid Technologies (Wolters Kluwer Health))-Vol. 30, Iss: 5, pp 501-506
TL;DR: In this article, a review on pathophysiology, assessment of kidney function, new definitions, and treatment and prevention of hepatorenal syndrome (HRS) is presented.
Abstract: Purpose of review Hepatorenal syndrome (HRS) is encountered frequently in patients with end-stage liver disease and remains an important cause of morbidity and mortality in this patient population. This review will focus and provide updates on pathophysiology, assessment of kidney function, new definitions, and treatment and prevention of HRS. Recent findings Pathophysiology of HRS has been elucidated more recently and in addition to hemodynamic changes, the role of systemic inflammatory response contributes significantly to this process. Assessment of kidney function in patients with liver cirrhosis remains challenging. Novel glomerular filtration rate equations have been developed in patients with liver disease to better estimate kidney function and changes made in the definition of acute kidney injury (AKI), which are more aligned with KDIGO criteria for AKI. Vasoconstrictors, especially terlipressin, along with albumin remain the mainstay of pharmacological treatment of HRS-AKI. Biomarkers have been useful in differentiating ATN from HRS at an early stage. Summary HRS remains a significant cause of morbidity and mortality for patients with end-stage liver disease. Newer understanding of mechanisms in development and pathophysiology of HRS have helped with elucidation of the disease process.
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TL;DR: In-hospital mortality of hepatorenal syndrome in the United States: Nationwide inpatient sample as discussed by the authors, inpatient samples were collected from the Centers for Disease Control and Prevention (CDC).
Abstract: In-hospital mortality of hepatorenal syndrome in the United States: Nationwide inpatient sample
7 citations
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TL;DR: The panel of experts, having emphasised the importance of initiating aetiologic treatment for any degree of hepatic disease at the earliest possible stage, extended its work to all the complications of cirrhosis which had not been covered by the European Association for the Study of the Liver guidelines.
1,534 citations
University of Padua1, University of Toronto2, University of Bologna3, University of Arizona4, Ludwig Maximilian University of Munich5, Paris Diderot University6, French Institute of Health and Medical Research7, Royal Free Hospital8, University College London9, University of Calgary10, University of Milan11, Stanford University12, University of Barcelona13, Yale University14
TL;DR: The scientific evidence is reported supporting the final proposal of a new approach to the diagnosis and treatment of acute kidney injury (AKI), on which the experts agreed.
610 citations
University of Alberta1, University of Toronto2, University Health Network3, Monash University4, Peking Union Medical College Hospital5, Paris Diderot University6, Peking Union Medical College7, The George Institute for Global Health8, University of Paris9, Ghent University Hospital10, Innsbruck Medical University11, Vita-Salute San Raffaele University12, University of California, San Francisco13, Auckland City Hospital14, University of Kentucky15, University College Dublin16, Guy's and St Thomas' NHS Foundation Trust17, United States Department of Veterans Affairs18, French Institute of Health and Medical Research19, Southeast University20, McMaster University21, University Hospital of Lausanne22, London Health Sciences Centre23, University of Münster24
TL;DR: Among critically ill patients with acute kidney injury, an accelerated renal-replacement strategy was not associated with a lower risk of death at 90 days than a standard strategy, and the most effective timing for the initiation of such therapy remains uncertain.
Abstract: Background Acute kidney injury is common in critically ill patients, many of whom receive renal-replacement therapy. However, the most effective timing for the initiation of such therapy remains uncertain. Methods We conducted a multinational, randomized, controlled trial involving critically ill patients with severe acute kidney injury. Patients were randomly assigned to receive an accelerated strategy of renal-replacement therapy (in which therapy was initiated within 12 hours after the patient had met eligibility criteria) or a standard strategy (in which renal-replacement therapy was discouraged unless conventional indications developed or acute kidney injury persisted for >72 hours). The primary outcome was death from any cause at 90 days. Results Of the 3019 patients who had undergone randomization, 2927 (97.0%) were included in the modified intention-to-treat analysis (1465 in the accelerated-strategy group and 1462 in the standard-strategy group). Of these patients, renal-replacement therapy was performed in 1418 (96.8%) in the accelerated-strategy group and in 903 (61.8%) in the standard-strategy group. At 90 days, death had occurred in 643 patients (43.9%) in the accelerated-strategy group and in 639 (43.7%) in the standard-strategy group (relative risk, 1.00; 95% confidence interval [CI], 0.93 to 1.09; P = 0.92). Among survivors at 90 days, continued dependence on renal-replacement therapy was confirmed in 85 of 814 patients (10.4%) in the accelerated-strategy group and in 49 of 815 patients (6.0%) in the standard-strategy group (relative risk, 1.74; 95% CI, 1.24 to 2.43). Adverse events occurred in 346 of 1503 patients (23.0%) in the accelerated-strategy group and in 245 of 1489 patients (16.5%) in the standard-strategy group (P Conclusions Among critically ill patients with acute kidney injury, an accelerated renal-replacement strategy was not associated with a lower risk of death at 90 days than a standard strategy. (Funded by the Canadian Institutes of Health Research and others; STARRT-AKI ClinicalTrials.gov number, NCT02568722.).
295 citations
University of Bologna1, Sapienza University of Rome2, University of Padua3, University of Turin4, University of Catania5, Academy for Urban School Leadership6, University of Florence7, University of Palermo8, University of Naples Federico II9, University of Udine10, The Catholic University of America11, University of Rome Tor Vergata12, Seconda Università degli Studi di Napoli13, University of Bari14, Catholic University of the Sacred Heart15, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico16
TL;DR: Long-term HA administration prolongs overall survival and might act as a disease modifying treatment in patients with decompensated cirrhosis in this trial.
290 citations
TL;DR: Tepatorenal syndrome (HRS), a serious complication of cirrhosis, is associated with high mortality without treatment and midodrine and octreotide plus albumin are used as an alternative treatment of HRS.
253 citations