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Cheung et al. Hepatorenal syndrome before liver transplantation

parenchymal renal failure, hypovolemia or infection use of terlipressin in liver transplantation. Patients
associated renal failure. with reversal of HRS before liver transplantation were
reported to have a similar postoperative outcome to
Molecular adsorbent recirculating system (MARS) was patients without HRS. However, Rodriguez et al.
[9]
[43]
used in bridging fulminant hepatic failure and acute reported a contradicting result. In their cohort of
on chronic hepatic failure patients to orthotopic liver 46 patients with type-2 HRS who underwent liver
transplantation. It represents a cell-free liver dialysis transplantation, 15 patients received terlipressin
[35]
or albumin dialysis, and helps to remove albumin- and albumin and had reversal of type-2 HRS. The
bound substances accumulating in liver failure. remaining 31 patients had either relapse or no
[36]
A randomized controlled trial by Mitzner et al. response or did not receive terlipressin and albumin.
[37]
compared type 1 HRS patients treated with volume The 2 groups had no significant differences with
expansion, dopamine, and haemodynamic filtration vs. respect to development of postoperative acute kidney
the same plus MARS. The result showed a significantly injury, frequency of chronic kidney disease at 1 year,
better survival for treatment group at 1 month. Even and 1-year and 3-year survival.
though there was improvement of 1-month survival,
one criticism of the study was that it only had one A randomized controlled trial was conducted to compare
long-term survivor (more than 1 month) and thus it the hemodynamic effects of perioperative terlipressin
had little clinical relevance. The improvement in serum infusion during living donor liver transplantation. In
[44]
creatinine and bilirubin may merely reflect the effect of this trial, intraoperative terlipressin infusion significantly
albumin dialysis, without a significant change in liver decreased hepatic and renal arterial resistive indices,
and renal function. Further trials to evaluate this portal venous blood flow and systemic arterial pressure
[38]
strategy will be needed. with lower systemic vascular resistance. The need
for intraoperative vasoactive support was reduced.
LIVER TRANSPLANTATION Terlipressin was continued for three postoperative
days. Postoperative renal function was better in the
Liver transplantation is the definitive treatment of terlipressin group.
HRS. However, due to the scarcity of liver grafts, most
patients died while awaiting transplantation. Acute FUTURE PERSPECTIVES
[2]
liver decompensation with type-1 HRS has worse
outcome after liver transplantation than that without HRS is a life-threatening complication of liver
HRS. Chok et al. reported 104 patients with acute cirrhosis and carries a poor prognosis. With a better
[39]
liver decompensation who received living donor liver understanding of the pathophysiology and advances
transplantation. Among them, 33 patients had HRS. in therapeutic strategies, there is hope to reduce its
These 33 patients had longer stay in the intensive care prevalence and improve patient outcome. Vasopressor
unit, more hemodialysis, more blood transfusions, worse treatment, such as that with terlipressin together with
postoperative renal function at 1 year and poorer overall volume expander (i.e. albumin), has been shown to
survival. However, 5-year overall survival was still nearly be an important strategy to stabilize patients and
80%, which is satisfactory. The authors concluded that bridge them to liver transplantation, which is the
living donor liver transplantation should be considered only definitive treatment. It would be interesting to
for such patients. Other centers also reported similar know the impact on prognosis in future after revising
outcome. [40,41] Some patients with a longer duration of type- the diagnostic criteria and initiating treatment in an
1 HRS before liver transplantation were reported to have earlier phase. Moreover, studies showed contradicting
non-reversal of HRS after transplantation. Wong et al. results on whether the short-term survival benefit of
[42]
analyzed the 15 patients with non-reversal of HRS terlipressin in patients with HRS, or the reversal of
among the 62 HRS patients with liver transplantation. HRS, would translate into a better long-term outcome
They found a 6% increased risk of non-reversal with after liver transplantation. Further well-designed trials
each additional day of pre-transplant dialysis. This has are needed to address this question.
illustrated that timely liver transplantation can improve
the outcome of HRS patients. Authors’ contributions
Design of the review: K.S.H. Chok
PERIOPERATIVE USE OF TERLIPRESSIN Literature review and manuscript writing: C.Y. Cheung
AND REVERSAL OF HRS IN LIVER Manuscript revision: K.S.H. Chok
TRANSPLANTATION
Financial support andsponsorship
There are little data regarding the role of perioperative None.
70 Hepatoma Research ¦ Volume 3 ¦ April 12, 2017