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Hepatorenal Disorders
Ali Al-Khafaji1, Mitra K Nadim2, John A Kellum1
1Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
Chest
|March 27, 2015
Summary
Hepatorenal syndrome (HRS) is a serious kidney complication in end-stage liver disease (ESLD). Management involves bridging to liver transplant with medical therapies and supportive renal treatments.
Area of Science:
- Nephrology
- Hepatology
- Gastroenterology
Background:
- Renal dysfunction is prevalent in end-stage liver disease (ESLD), encompassing various acute and chronic kidney injuries.
- Hepatorenal syndrome (HRS) is a specific hepatorenal disorder (HRD) with distinct pathophysiology, affecting an estimated 35-40% of ESLD patients with ascites.
- HRS involves splanchnic arterial vasodilatation and reduced intravascular volume, leading to renal vasoconstriction and decreased blood flow.
Purpose of the Study:
- To describe the pathophysiology, subtypes, diagnosis, and management of hepatorenal syndrome (HRS) in patients with end-stage liver disease (ESLD).
Main Methods:
- Diagnosis of HRS is established by excluding other causes of renal dysfunction due to the absence of specific diagnostic tests.
- Classification includes Type 1 HRS (rapidly progressive) and Type 2 HRS (slowly deteriorating renal function).
- Treatment strategies involve medical management (volume expansion, vasoconstrictors) as a bridge to liver transplantation.
Main Results:
- Type 1 HRS can be precipitated by sepsis or alcoholic hepatitis and may evolve from Type 2 HRS.
- Transjugular intrahepatic portosystemic shunt (TIPS) has been explored, but evidence of efficacy compared to standard therapy is limited.
- Renal replacement therapy is considered for liver transplant candidates.
Conclusions:
- Liver transplantation remains the definitive treatment for HRS.
- Medical management and supportive renal therapies are crucial for patients awaiting transplant.
- Artificial liver assist devices are currently under investigation.
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