[Hepatorenal syndrome]

Functional renal disorders commonly complicate cirrhosis and ascits, and in its terminal stage is known as hepatorenal syndrome (HRS). HRS is defined as the development of renal failure in patients with advanced liver failure (acute or chronic) in the absence of other identifiable causes of renal pathology. It is a syndrome characterized by oliguria, severe renal sodium retention, circulatory instability with marked systemic arterial vasodilatation and activation vasoactive systems. Signs of renal functional impairment may be observed in more than 30% of patients with cirrhosis and ascites, but only about 5% showed typical signs of HRS. In patients with decompensated cirrhosis, HRS has been found in about 18% after 1 year and in 40% after 5 years of follow up. In this survey are showed the diagnostic criteria for HRS as set out by the International Ascites Club. According to this criteria HRS was considered present when serum creatinine was > 1.5 mg/dl and creatinine clearance < 40 ml/min. Several therapeutic approaches have been proposed to modify the altered systematic and renal hemodynamics occurring during HRS. Administration of plasma expanders or vasoconstricting drugs, peritoneovenous shunting, portosystemic shunts and transjugular intrahepatic portosystemic shunts have been used to reverse peripheral vasodilatation and improve vascular underfilling. Renal vasodilatators and prostaglandins have been administered to reduce renal vasoconstriction. Theoretically the ideal treatment for patients with HRS is liver transplantation. The prognosis for HRS is poor and treatment almost always unsatisfactory when liver transplantation is excluded. The best treatment of HRS is preventing precipitating factors.