Abstract

MAGRICO, Rita; MATEUS, Ana  and  RAMOS, Aura. What’s new in hepatorenal syndrome? An updated review for the nephrologist. Port J Nephrol Hypert [online]. 2013, vol.27, n.4, pp.249-260. ISSN 0872-0169.

In advanced cirrhosis, increased levels of vasodilators and impaired cardiac compensatory response decrease effective arterial blood volume, causing vasoconstriction of renal arteries and kidney failure in up to 40% of patients after 5 years of follow-up. Hepatorenal syndrome (HRS) diagnostic criteria are: cirrhosis with ascites; serum creatinine (SCr) > 1.5 mg/dL (with no improvement 2 days after diuretic withdrawal and albumin administration). Shock, nephrotoxics and acute parenchymal kidney disease must be excluded. The HRS is classified in: type 1, defined by a 100% increase in SCr to > 2.5 mg/dL in < 2 weeks, and type 2, with a slower and milder decrease in kidney function. Type 3 HRS is an emerging concept, referring to HRS in patients with coexistent kidney disease. Left untreated, average survival of type 1 HRS is 2 weeks whereas in type 2 it is 6 months. Treatment of HRS lies on reversal of the hepatic disease or liver transplantation (combined liver-kidney transplant may be appropriate for patients who have been on renal replacement therapy (RRT) for more than 8 weeks). However, with today’s available therapy, there may be reversibility of HRS without liver transplant. Type 1 HRS is treated with vasoconstrictors (mainly terlipressin; noradrenalin may be an alternative in patients in intensive care units) and albumin. Reversal of HRS occurs in about half of patients. If SCr does not decrease and patients have classic indications for dialysis, RRT can be used as a second-line treatment until liver recovery or transplant. MARS (molecular readsorbent recirculating systems) and Prometheus systems should be considered experimental. Type 2 HRS treatment is based on repeated large-volume paracentesis and albumin administration. If ineffective, vasconstrictors are used. Since renal impairment is mild, RRT is not indicated. If liver recovery/transplant are unfeasible, patient’s treatment should avoid futilities.

Keywords : Dialysis; hepatorenal syndrome; kidney failure; liver cirrhosis; terlipressin.

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