TITLE:
Hepatorenal Syndrome
AUTHORS:
Tyree H. Kiser
KEYWORDS:
Hepatorenal Disorder; Cirrhosis; Portal Hypertension; Transplantation; Vasopressors
JOURNAL NAME:
International Journal of Clinical Medicine,
Vol.5 No.3,
January
24,
2014
ABSTRACT: Hepatorenal syndrome (HRS) is the most serious
hepatorenal disorder and one of the most difficult to treat. To date, the best
treatment options are those that reverse the mechanisms underlying HRS: portal
hypertension, splanchnic vasodilation, and/or renal vasoconstriction.
Therefore, liver transplantation is the preferred definitive treatment option.
The role of other therapies is predominantly to prolong survival sufficiently
to allow patients to undergo transplantation. Terlipressin with the addition of
adjunctive albumin volume expansion is the preferred pharmacologic therapy for
the treatment of patients with HRS. Norepinephrine and vasopressin are acceptable
alternatives in countries where terlipressin is not yet available. For patients
with Type II HRS, midodrine plus octreotide appears to be an effective
pharmacologic regimen that can be administered outside of an intensive care
unit setting. Regardless of chosen vasoconstrictor therapy, careful monitoring
is needed to ensure tissue ischemia and severe adverse effects do not occur.
Artificial hepatic support devices, renal replacement therapy, and transjugular
intrahepatic portosystemic shunt (TIPS) are non-pharmacologic options for patients
with HRS. However, hepatic support devices and renal replacement therapies have
not yet demonstrated improved outcomes and TIPS is difficult to be employed in
patients with Type I HRS due to contraindications in the majority of patients.
Despite advances in our understanding of hepatorenal syndrome, the disease is
still associated with significant morbidity, mortality, and costs. More
evidence is urgently needed to help improve patient outcomes in this difficult-to-treat
population.