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Cheung et al. Hepatorenal syndrome before liver transplantation

Table 1: Comparison of three versions of the International Ascites Club diagnostic criteria of HRS-1
1996 2007 2015
Major criteria Criteria Criteria
Chronic or acute liver disease with advanced Presence of cirrhosis with ascites Presence of cirrhosis with ascites
hepatic failure and portal hypertension
Low glomerular filtration rate: sCr > 1.5 mg/mL sCr > 1.5 mg/dL Diagnosis of acute kidney injury (increase in
or 24 h sCr clearance < 40 mL/min sCr ≥ 0.3 mg/dL or 1.5 times over baseline)
No sustained improvement in renal function No improvement of sCr after at least No improvement of sCr after at least 2 days
following diuretic withdrawal and expansion 2 days of diuretic withdrawal and of diuretics withdrawal and volume expansion
of plasma volume with at least 1,500 mL of volume expansion with albumin with albumin (1 g/kg of body weight per day
isotonic saline (1 g/kg of body weight per day up to a up to a maximum of 100 g/day)
maximum of 100 g/day)
Absence of shock, ongoing bacterial infection Absence of shock Absence of shock
No treatment with nephrotoxic drugs or No current or recent treatment with No current or recent treatment with
gastrointestinal or renal fluid losses nephrotoxic drugs nephrotoxic drugs
Proteinuria < 0.5 g/day and no evidence of No macroscopic signs of structural No macroscopic signs of structural
obstructive nephropathy or parenchymal renal kidney injury: normal findings on kidney injury: normal findings on renal
disease on ultrasound renal ultrasonography, absence of ultrasonography, absence of proteinuria
proteinuria > 500 mg/day and absence > 500 mg/day and absence of microhematuria
of microhematuria
Additional criteria
Urinary volume < 0.5 L/day
Urinary sodium < 10 mmol/L
Urinary osmolality > plasma osmolality
Urinary red blood cells < 50/HPF
Serum sodium < 130 mmol/L
HRS: hepatorenal syndrome; sCr: serum creatinine; HPF: high power field
HRS since 2002. A meta-analysis in 2014 identified reduction in activity of the renin-angiotensin and
[26]
four small randomized trials comparing noradrenaline sympathetic nervous systems. Another small study
[30]
and terlipressin in the treatment of HRS. The 4 also demonstrated an improvement in renal function
[27]
studies comprising 154 patients showed no differences after TIPS in 18 patients with type 2 HRS awaiting
between terlipressin and noradrenaline in reversal of orthotopic liver transplant. A non-randomized
[31]
HRS, mortality at 30 days, and recurrence of HRS. comparative study of 41 HRS patients (31 with
Adverse events, mainly abdominal cramps, were less TIPS performed, and another 10 in which TIPS was
common with noradrenaline. contraindicated due to advanced liver failure), type 1
and 2 included, showed that renal functions improved 2
Midodrine is another alpha-adrenergic agent weeks after TIPS and with better survivals. However,
[32]
commonly used in the United States as an alternative the study was heavily biased towards the intervention
to terlipressin, and is used in combination with arm due to patient selection. Wong et al. further
[33]
octreotide and albumin. Skagen et al. reported a demonstrated in their case series the additional benefit
[28]
case control study comparing 75 HRS patients who of TIPS on top of Midodrine, octreotide and albumin,
received the triple therapy with a historical cohort of in improving renal function and sodium excretion for
87 HRS patients who did not. It showed a significantly type 1 HRS patients. Despite these evidence, TIPS
better transplant-free survival, overall survival and is a risky procedure, if not contraindicated, in HRS
renal function at 1 month. patients requiring liver transplantation who have
advanced liver failure. Procedural-related mortality
Besides the use of vasopressors and albumin, was also reported. Thus, the role of TIPS in bridging
[32]
transjugular intrahepatic portosystemic shunt (TIPS) HRS patients to liver transplantation remains limited to
and extracorporeal albumin dialysis were also used to selected patients.
treat HRS in some centers. TIPS is a percutaneously
created low-resistance channel between portal vein Renal replacement therapy (RRT) has been provided
and hepatic vein with the aim of reducing the portal to cirrhotic patients with acute kidney injury, with
pressure by shunting blood from the portal to the indications no different from other patients with acute
systemic circulation. Few studies have evaluated kidney injury. However, the renal failure was caused
[29]
[34]
the effectiveness of TIPS in treating HRS. In 6 out of 7 by HRS in only 13% of these patients. The 3-month
patients with type 1 HRS, renal function improved 30 survival was only 15% in these patients without
days after TIPS, which was associated with a significant liver transplant, which was the lowest comparing to
Hepatoma Research ¦ Volume 3 ¦ April 12, 2017 69