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Arch Hellen Med, 28(3), May-June 2011, 323-335


Current views on the hepatorenal syndrome

S.P. Dourakis
Second Department of Medicine, "Hippokration" General Hospital, Medical School, Athens, Greece

In recent years, substantial progress has been made towards understanding the pathogenesis and natural history of renal failure in cirrhosis of the liver. Novel forms of clinical intervention may assist in the prevention and management of this complication. In the advanced stages of cirrhosis, systemic vascular resistance is markedly reduced, and additional increases in cardiac output cannot compensate, leading to underfilling of the arterial circulation. There is evidence, also, that cardiac output decreases as cirrhosis progresses. Hepatorenal syndrome is a frequent cause of renal failure in cirrhosis and is characterized by functional renal vasoconstriction that leads to a severe reduction in the glomerular filtration rate (GFR), with minimal renal histological abnormalities. Since there are no specific diagnostic tests, a combination of several diagnostic criteria is used. Bacterial infections (particularly spontaneous bacterial peritonitis caused by bacterial translocation of Gram negative bacteria) often precipitate renal failure. In some patients the hepatorenal syndrome may be reversible after resolution of the infection, but in others, it may persist or even progress rapidly despite successful treatment of the infection. The hepatorenal syndrome can be classified into two types, each with different clinical and prognostic characteristics. Type 1 is characterized by a doubling of the serum creatinine concentration (to above 2.5 mg/dL) in less than 2 weeks; type 2 follows a stable, less progressive course, characterized mainly by refractory ascites. Vasopressin analogues (e.g., terlipressin) in conjunction with albumin are effective in approximately 40% to 50% of patients with the hepatorenal syndrome and should be considered as initial therapy. Other vasoconstrictors, including alpha-adrenergic agonists such as norepinephrine and midodrine (with or without octreotide) in conjunction with albumin, appear to be effective, but information on their use is limited.

Key words: Alpha-adrenergic agonists, Hepatorenal syndrome, Midodrine, Norepinephrine, Terlipressin, Vasoconstriction.

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