Limits...
Hepatorenal syndrome: aetiology, diagnosis, and treatment.

Low G, Alexander GJ, Lomas DJ - Gastroenterol Res Pract (2015)

Bottom Line: A variety of types of renal impairment are recognised.The most important of these is the hepatorenal syndrome, a functional renal impairment due to circulatory and neurohormonal abnormalities that underpin cirrhosis.This paper provides a comprehensive and up-to-date review of hepatorenal syndrome and lays out the topic according to the following sections: pathophysiology, historical developments, diagnostic criteria and limitations, epidemiology, precipitating factors, predictors, clinical and laboratory findings, prognosis, treatment options, prophylaxis, and conclusion.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK ; University of Alberta, Edmonton, AB, Canada T6G 2B7 ; University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, P.O. Box 218, Cambridge CB2 0QQ, UK.

ABSTRACT
Acute renal impairment is common in patients with chronic liver disease, occurring in approximately 19% of hospitalised patients with cirrhosis. A variety of types of renal impairment are recognised. The most important of these is the hepatorenal syndrome, a functional renal impairment due to circulatory and neurohormonal abnormalities that underpin cirrhosis. It is one of the most severe complications of cirrhosis with survival often measured in weeks to months. A variety of treatment options exist with early diagnosis and appropriate treatment providing the best hope for cure. This paper provides a comprehensive and up-to-date review of hepatorenal syndrome and lays out the topic according to the following sections: pathophysiology, historical developments, diagnostic criteria and limitations, epidemiology, precipitating factors, predictors, clinical and laboratory findings, prognosis, treatment options, prophylaxis, and conclusion.

No MeSH data available.


Related in: MedlinePlus

Probability of survival in cirrhotic patients with different types of renal impairment: nonazotemic patients (bold continuous line), type 2 HRS (dotted line), and type 1 HRS (continuous line) (reproduced with permission from “BMJ Publishing Group Limited,” Salerno et al. [16]).
© Copyright Policy - open-access
Related In: Results  -  Collection


getmorefigures.php?uid=PMC4306364&req=5

fig2: Probability of survival in cirrhotic patients with different types of renal impairment: nonazotemic patients (bold continuous line), type 2 HRS (dotted line), and type 1 HRS (continuous line) (reproduced with permission from “BMJ Publishing Group Limited,” Salerno et al. [16]).

Mentions: HRS is one of the most lethal complications of cirrhosis (Figure 2). Prognosis is invariably poor ranging from months in type 2 HRS to weeks to months in type 1 HRS [42, 43]. Studies have been performed to define clinical parameters that track survival in HRS. In 2005, Alessandria et al. studied 105 patients with cirrhosis and HRS (39% type 1 and 61% type 2) [42] and found that HRS type and MELD (model for end-stage liver disease) score were variables that associated independently with survival on multivariate analysis. MELD is an internationally recognised scoring system developed for patients with advanced liver disease that is a predictor of three-month mortality and determines priority listing for liver transplantation [42, 44]. It is calculated according to the following formula: 9.6 × log⁡e (creatinine mg/dL) + 3.8 × log⁡e (bilirubin mg/dL) + 11.2 × log⁡e (international normalised ratio, INR) + 6.4 [42]. Patients with type 1 HRS had a MELD score ≥ 20 and a median survival of one month [42]. For type 2 HRS, the median survival was 11 months for a MELD score < 20 and three months for a MELD score ≥ 20 [42]. Schepke et al. reported similar findings in a 2006 study that involved 88 patients with cirrhosis and renal failure [43], some with HRS (17–39.8% type 1, 22.7% type 2), and non-HRS renal impairment. On multivariate analysis, the authors found that type 1 HRS and the MELD score were independent variables associated with survival. The mean MELD score was higher in patients with HRS than in patients with non-HRS renal impairment (23.8 versus 18.3, P = 0.002) [43]. The estimated survival time was 3.4 months for type 1 HRS, 10.9 months for type 2 HRS, and 16.1 months for non-HRS renal impairment [43]. In 2010, Yang et al. performed a longitudinal assessment of prognostic factors in 103 patients with HRS (65% type 1 and 35% type 2) [45] and revealed that temporal changes (Δ) in four clinical parameters were associated with survival on time dependent multivariate analysis. These parameters included Δ MELD score simple, Δ serum creatinine, Δ serum bilirubin, and Δ serum albumin [45]. Δ MELD score simple was calculated according to the following formula: [3.8 × log bilirubin (mg/dL)] + 9.6 × log [creatinine (mg/dL) + 6.43] [45]. The authors found that Δ MELD score simple was superior to baseline and changes in MELD score in predicting prognosis. The authors also found that increasing serum creatinine and bilirubin affected survival adversely, while increasing serum albumin had a beneficial effect. In a 2012 study involving 68 patients with type 1 HRS, Martinez et al. reported that the aetiology of the liver disease, the serum creatinine at the time of initiation of treatment, and the urinary sodium were useful prognostic factors [46]. The aetiologies of the liver disease included (in decreasing order of survival) autoimmune hepatitis, cardiac, idiopathic, viral, viral + alcohol, alcohol, and neoplasia. The authors also found that higher serum creatinine on admission and a urinary sodium < 5 mEq/L were associated negatively with survival.


Hepatorenal syndrome: aetiology, diagnosis, and treatment.

Low G, Alexander GJ, Lomas DJ - Gastroenterol Res Pract (2015)

Probability of survival in cirrhotic patients with different types of renal impairment: nonazotemic patients (bold continuous line), type 2 HRS (dotted line), and type 1 HRS (continuous line) (reproduced with permission from “BMJ Publishing Group Limited,” Salerno et al. [16]).
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4306364&req=5

fig2: Probability of survival in cirrhotic patients with different types of renal impairment: nonazotemic patients (bold continuous line), type 2 HRS (dotted line), and type 1 HRS (continuous line) (reproduced with permission from “BMJ Publishing Group Limited,” Salerno et al. [16]).
Mentions: HRS is one of the most lethal complications of cirrhosis (Figure 2). Prognosis is invariably poor ranging from months in type 2 HRS to weeks to months in type 1 HRS [42, 43]. Studies have been performed to define clinical parameters that track survival in HRS. In 2005, Alessandria et al. studied 105 patients with cirrhosis and HRS (39% type 1 and 61% type 2) [42] and found that HRS type and MELD (model for end-stage liver disease) score were variables that associated independently with survival on multivariate analysis. MELD is an internationally recognised scoring system developed for patients with advanced liver disease that is a predictor of three-month mortality and determines priority listing for liver transplantation [42, 44]. It is calculated according to the following formula: 9.6 × log⁡e (creatinine mg/dL) + 3.8 × log⁡e (bilirubin mg/dL) + 11.2 × log⁡e (international normalised ratio, INR) + 6.4 [42]. Patients with type 1 HRS had a MELD score ≥ 20 and a median survival of one month [42]. For type 2 HRS, the median survival was 11 months for a MELD score < 20 and three months for a MELD score ≥ 20 [42]. Schepke et al. reported similar findings in a 2006 study that involved 88 patients with cirrhosis and renal failure [43], some with HRS (17–39.8% type 1, 22.7% type 2), and non-HRS renal impairment. On multivariate analysis, the authors found that type 1 HRS and the MELD score were independent variables associated with survival. The mean MELD score was higher in patients with HRS than in patients with non-HRS renal impairment (23.8 versus 18.3, P = 0.002) [43]. The estimated survival time was 3.4 months for type 1 HRS, 10.9 months for type 2 HRS, and 16.1 months for non-HRS renal impairment [43]. In 2010, Yang et al. performed a longitudinal assessment of prognostic factors in 103 patients with HRS (65% type 1 and 35% type 2) [45] and revealed that temporal changes (Δ) in four clinical parameters were associated with survival on time dependent multivariate analysis. These parameters included Δ MELD score simple, Δ serum creatinine, Δ serum bilirubin, and Δ serum albumin [45]. Δ MELD score simple was calculated according to the following formula: [3.8 × log bilirubin (mg/dL)] + 9.6 × log [creatinine (mg/dL) + 6.43] [45]. The authors found that Δ MELD score simple was superior to baseline and changes in MELD score in predicting prognosis. The authors also found that increasing serum creatinine and bilirubin affected survival adversely, while increasing serum albumin had a beneficial effect. In a 2012 study involving 68 patients with type 1 HRS, Martinez et al. reported that the aetiology of the liver disease, the serum creatinine at the time of initiation of treatment, and the urinary sodium were useful prognostic factors [46]. The aetiologies of the liver disease included (in decreasing order of survival) autoimmune hepatitis, cardiac, idiopathic, viral, viral + alcohol, alcohol, and neoplasia. The authors also found that higher serum creatinine on admission and a urinary sodium < 5 mEq/L were associated negatively with survival.

Bottom Line: A variety of types of renal impairment are recognised.The most important of these is the hepatorenal syndrome, a functional renal impairment due to circulatory and neurohormonal abnormalities that underpin cirrhosis.This paper provides a comprehensive and up-to-date review of hepatorenal syndrome and lays out the topic according to the following sections: pathophysiology, historical developments, diagnostic criteria and limitations, epidemiology, precipitating factors, predictors, clinical and laboratory findings, prognosis, treatment options, prophylaxis, and conclusion.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK ; University of Alberta, Edmonton, AB, Canada T6G 2B7 ; University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, P.O. Box 218, Cambridge CB2 0QQ, UK.

ABSTRACT
Acute renal impairment is common in patients with chronic liver disease, occurring in approximately 19% of hospitalised patients with cirrhosis. A variety of types of renal impairment are recognised. The most important of these is the hepatorenal syndrome, a functional renal impairment due to circulatory and neurohormonal abnormalities that underpin cirrhosis. It is one of the most severe complications of cirrhosis with survival often measured in weeks to months. A variety of treatment options exist with early diagnosis and appropriate treatment providing the best hope for cure. This paper provides a comprehensive and up-to-date review of hepatorenal syndrome and lays out the topic according to the following sections: pathophysiology, historical developments, diagnostic criteria and limitations, epidemiology, precipitating factors, predictors, clinical and laboratory findings, prognosis, treatment options, prophylaxis, and conclusion.

No MeSH data available.


Related in: MedlinePlus