Abstract
Definition and diagnostic criteria for hepatorenal syndrome (HRS) established in 19941 were based on the following three concepts:
-
1.
Renal failure in HRS is functional and caused by marked intrarenal arteriolar vasoconstriction.
-
2.
HRS occurs in the setting of a systemic circulatory dysfunction caused by extrarenal vasodilation.
-
3.
Plasma volume expansion does not improve renal failure.
Four new concepts have emerged since then:
-
1.
Extrarenal arterial vasodilation mainly occurs in the splanchnic bed, whereas other major vascular beds, such as the brain and the liver, may be vasoconstricted. This may contribute to some of the frequent extrarenal complications, i.e. progressive hepatic failure and encephalopathy.
-
2.
Cardiac output in patients with HRS may be low, normal, or high, but all the same it is insufficient because of the reduced peripheral vascular resistance. This may aggravate the systemic circulatory dysfunction of HRS.
-
3.
The most frequent trigger of type 1 HRS is bacterial infection, mainly spontaneous bacterial peritonitis (SBP).
-
4.
HRS is not always a terminal event as it can be improved by medical treatment, and the improvement is associated with improved survival.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
Preview
Unable to display preview. Download preview PDF.
Similar content being viewed by others
References
Arroyo V, Gines P, Gerbes A et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. Hepatology. 1996;23:164–76.
Fernandez-Seara J, Prieto J, Quiroga J et al. Systemic and regional hemodynamics in patients with liver cirrhosis and ascites with and without functional renal failure. Gastroenterology. 1989;97:1304–12.
Maroto A, Gines P, Arroyo V et al. Brachial and femoral artery blood flow in cirrhosis: relationship to kidney dysfunction. Hepatology. 1993;17:788–93.
Rivolta R, Maggi A, Cazzaniga M et al. Reduction of renal cortical blood flow assessed by Doppler in cirrhotic patients with refractory ascites. Hepatology. 1998;28:1235–40.
Guevara M, Bru C, Gines P et al. Increased cerebrovascular resistance in cirrhotic patients with ascites. Hepatology. 1998;28:39–44.
Sacerdoti D, Bolognesi M, Merkel C, Augeli P, Gatta A. Renal vasoconstriction in cirrhosis evaluated by duplex Doppler ultrasonography. Hepatology. 1993;17:219–24.
Sugano S, Yamamoto K, Atobe T et al. Posiprandial middle cerebral arterial vasoconstriction in cirrhotic patients. A placebo, controlled evaluation. J Hepatol. 2001;34:373–7.
Dillon JF, Pleyris JN, Wong FC et al. Middle cerebral artery blood flow velocity in patients with cirrhosis. Eur J Gastroenterol Hepatol. 1995;7:1087–91.
Moller S, Henriksen J. The systemic circulation in cirrhosis. In: Gines P, Arroyo V, Rodes J, Schrier RW, editors. Ascites and Renal Dysfunction in Liver Disease, 2nd edn. Oxford: Blackwell, 2005:139–55.
Luca A, Garcia-Pagan JC, Feu F et al. Noninvasive measurement of femoral blood flow and portal pressure response to propranolol in patients with cirrhosis. Hepatology. 1995;21:83–8.
Piscaglia F, Zironi G, Gaiani S et al. Relationship between splanchnic, peripheral and cardiac hemodynamics in cirrhosis of different degrees of severity. Eur J Gastroenterol Hepatol. 1997;9:799–804.
Wong F, Logan A, Blendis L. Hyperinsulinemia in preascitic cirrhosis: effects on systemic and renal hemodynamics, sodium homeostasis, forearm blood flow and sympathetic nervous activity. Hepatology. 1996;23:414–22.
Mitamura K, Kawauchi A, Sasaki K et al. Measurement of renal artery blood flow velocity by Doppler ultrasonography in chronic liver disease. Hepatol Res. 1999;15:201–14.
Domenicali M, Ros J, Fernandez-Varo G et al. Increased anandamide induced relaxation in mesenteric arteries of cirrhotic rats: role of cannabinoid and vanilloid receptors. Gut 2005;54:522–7.
Castro A, Jimenez W, Claria J et al. Impaired response to angiotensin II in experimental cirrhosis: role of nitric oxide. Hepatology. 1993;18:367–72.
Heller J, Schepke M, Gehnen N et al. Altered adrenergic responsiveness of endothelium-denuded hepatic arteries and portal veins in patients with cirrhosis. Gastroenterology. 1999;116:387–93.
Hartleb M, Moreau R, Cailmail S, Gaudin C, Lebrec D. Vascular hyporesponsiveness to endothelin 1 in rats with cirrhosis. Gastroenterology. 1994;107:1085–93.
Michielsen PP, Boeckxstaens GE, Sys SU, Herman AG, Pelckmans PA. The role of increased nitric oxide in the vascular hyporeactivity to noradrenaline in long-term portal vein ligated rats. J Hepatol. 1995;23:341–7.
Islam M, Williams B, Madhavan K, Hayes P, Hadoke P. Selective alteration of agonist-mediated contraction in hepatic arteries isolated from patients with cirrhosis. Gastroenterology. 2000;118:765–71.
Helmy A, Newby DE, Jalan R et al. Nitric oxide mediates the reduced vasoconstrictor response to angiotensina II in patients with preascitic cirrhosis. J Hepatol. 2003;38:44–50.
Tristani FE, Cohn JN. Systemic and renal hemodynamics in oliguric hepatic failure: effect of volume expansion. J Clin Invest 1967;46:1894–6.
Ruiz del Arbol L., Urman J, Fernandez J et al. Systemic, renal, and hepatic hemodynamic derangement in cirrhotic patients with spontaneous bacterial peritonitis. Hepatology. 2003;38:1210–18.
Ruiz del Arbol L, Monescillo A, Arocena C et al. Circulatory function and hepatorenal syndrome in cirrhosis. Hepatology. 2005;42:439–47.
Follo A, Llovet JM, Navasa M et al. Renal impairment after spontaneous bacterial peritonitis in cirrhosis: incidence, clinical course, predictive factors and prognosis. Hepatology. 1994;20:1495–501.
Terra C, Guevara M, Torre A et al. Renal failure in patients with cirrhosis and sepsis unrelated to spontaneous bacterial peritonitis: value of MELD score. Gastroenterology. 2005;129:1944–53.
Cardenas A, Gines P, Uriz J et al. Renal failure after upper gastrointestinal bleeding in cirrhosis: incidence, clinical course, predictive factors, and short-term prognosis. Hepatology. 2001;34:671–6.
Salerno F, Badalamenti S. Drug-induced renal failure in cirrhosis. In: Gines P, Arroyo V, Rodes J, Schrier RW, editors. Ascites and Renal Dysfunction in Liver Disease, 2nd edn. Oxford: Blackwell, 2005:372–82.
Moreau R, Lebrec D. The use of vasoconstrictors in patients with cirrhosis: type 1 HRS and beyond. Hepatology. 2006;43:385–94.
Guevara M, Ginès P, Fernandez-Esparrach G et al. Reversibility of hepatorenal syndrome by prolonged administration of ornipressin and plasma volume expansion. Hepatology. 1998;27:35–41.
Brensing KA, Textor J, Perz J et al. Long term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase II study. Gut. 2000;47:288–95.
Guevara M, Gines P, Bandi JC et al. Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: effects on renal function and vasoactive systems. Hepatology. 1998;28:416–22.
Shapiro MD, Nicholls Groves BM KM et al. Interrelationship between cardiac output and vascular resistance as determinant of effective arterial blood volume in cirrhotic patients. Kidney Int. 1985;28:206–11.
Hadengue A, Gadano A, Moreau R et al. Beneficial effects of the two-day administration of terlipressin in patients with cirrhosis and hepatorenal syndrome. J Hepatol. 1998;29:565–70.
Lenz K, Hortnagl H, Druml W et al. Ornipressin in the treatment of functional renal failure in decompensated cirrhosis: effects on renal hemodynamics and atrial natriuretic factor. Gastroenterology. 1991;101:1060–7.
Fernandez J, Navasa M, Garcia-Pagan JC et al. Effect of intravenous albumin on systemic and hepatic hemodynamics and vasoactive neurohormonal systems in patients with cirrhosis and spontaneous bacterial peritonitis. J Hepatol. 2004;41:384–90.
Bevers LM, van Faassen EE, Vuong TD et al. Low album in levels increased endothelial NO production and decrease vascular NO sensitivity. Nephrol Dial Transplant. 2006;21:3443–9.
Sort P, Navasa M, Arroyo V et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med. 1999;5:403–9.
Gülberg V, Bilzer M, Gerbes AL. Long-term therapy and retreatment of hepatorenal syndrome type 1 with ornipressin and dopamine. Hepatology. 1999;30:870–5.
Moreau R, Durand F, Poynard T et al. Terlipressin in patients with cirrhosis and type 1 hepatorenal syndrome: a retrospective multicenter study. Gastroenterology. 2002;122:923–30.
Uriz J, Ginès P, Cardenas A et al. Terlipressin plus albumin infusion: an effective and safe therapy of hepatorenal syndrome. J Hepatol. 2000;33:43–8.
Ortega R, Ginès P, Uriz J et al. Terlipressin therapy with and without albumin for patients with hepatorenal syndrome: results of a prospective nonrandomized study. Hepatology. 2002;36:941–8.
Angeli P, Guarda S, Fasolato S et al. Switch therapy with ciprofloxaxin vs. intravenous ceftazidime in the treatment of spontaneous bacterial peritonitis in patients with cirrhosis: similar efficacy at lower cost. Aliment Pharmacol Ther. 2006;23:75–84.
Wong F, Pantea L, Sniderman K. Midodrine, octreotide, albumin, and TIPS in selected patients with cirrhosis and type 1 hepatorenal syndrome. Hepatology. 2004;40:55–64.
Solanki P, Chawla A, Garg R et al. Beneficial effects of terlipressin in hepatorenal syndrome: a prospective, randomized placebo-controlled clinical trial. J Gastroenterol Hepatol. 2003;18:152–6.
Ortega R, Ginès P, Uriz J et al. Terlipressin therapy with and without albumin for patients with hepatorenal syndrome: results of a prospective nonrandomized study. Hepatology. 2002;36:941–8.
Pomier-Layrargues G, Paquin SC, Hassoun Z et al. Octreotide in hepatorenal syndrome: a randomized, double-blind, placebo-controlled, crossover study. Hepatology. 2003;38:238–43.
Duvoux C, Zanditenas D, Hezode C et al. Effects of noradrenalin and albumin in patients with type 1 hepatorenal syndrome: a pilot study. Hepatology. 2002;36:374–80.
Mulkay JP, Louis H, Donckier V et al. Long-term terlipressin administration improves renal function in cirrhotic patients with type 1 hepatorenal syndrome: a pilot study. Acta Gastroenterol Belg. 2001;64:15–19.
Testino G, Ferro C, Sumberaz A et al. Type-2 hepatorenal syndrome and refractory ascites: role of transjugular intrahepatic portosystemic stent-shunt in eighteen patients with advanced cirrhosis awaiting orthotopic liver transplantation. Hepatogastroenterology. 2003;50:1753–5.
Gerbes AL, Gulberg V. Benefit of TIPS for patients with refractory ascites: serum bilirubin may make the difference. Hepatology. 2005;41:217.
Jalan R, Forrest EH, Redhead DN, Dillon JF, Hayes PC. Reduction in renal blood flow following acute increase in the portal pressure: evidence for the existence of a hepatorenal reflex in man? Gut. 1997;40:664–70.
Sanyal A, Boyer T, Garcia-Tsao G et al. A prospective randomized double blind, placebo-controlled trial of terlipressin for type 1 hepatorenal syndrome (HRS). Hepatology. 2006;44(Suppl. 1): 694A (Abstract).
Salerno F, Cazzaniga M, Pagnozzi G et al. Humoral and cardiac effects of TIPS in cirrhotic patients with different ‘effective’ blood volume. Hepatology. 2003;38:1370–7.
Schwartz JM, Beymer C, Althaus SJ et al. Cardiopulmonary consequences of transjugular intrahepatic portosystemic shunts: role of increased pulmonary artery pressure. J Clin Gastroenterol. 2004;38:590–4.
Stange J, Ramlow W, Mitzner S, Schmidt R, Klinkmann H. Dialysis against a recycled albumin solution enables the removal of albumin-bound toxins. Artif Organs. 1993;17:809–13.
Sen S, Davies NA, Mookerjee RP et al. Pathophysiological effects of albumin dialysis in acute-on-chronic liver failure: a randomized controlled study. Liver Transplant. 2004;10:1109–19.
Mitzner SR, Stange J, Klammt S et al. Improvement of hepatorenal syndrome with extracorporeal albumin dialysis MARS: results of a prospective, randomized, controlled clinical trial. Liver Transplant. 2000;6:277–86.
Heemann U, Treichel U, Loock J et al. A dialysis in cirrhosis with superimposed acute liver injury: a prospective, controlled study. Hepatology. 2002;36:949–58.
Gerbes AL. The patient with refractory ascites. Best Pract Res Clin Gastroenterol. 2007;21:551–60.
Gerbes AL, Gulberg V. Progress in treatment of massive ascites and hepatorenal syndrome. World J Gastroenterol. 2006;12:516–19.
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2008 Springer and Falk Foundation e.V.
About this paper
Cite this paper
Gerbes, A.L. (2008). Hepatorenal syndrome in cirrhosis. In: Ferkolj, I., Gangl, A., Galle, P.R., Vucelic, B. (eds) Pathogenesis and Clinical Practice in Gastroenterology. Falk Symposium, vol 160. Springer, Dordrecht. https://doi.org/10.1007/978-1-4020-8767-7_21
Download citation
DOI: https://doi.org/10.1007/978-1-4020-8767-7_21
Publisher Name: Springer, Dordrecht
Print ISBN: 978-1-4020-8766-0
Online ISBN: 978-1-4020-8767-7
eBook Packages: MedicineMedicine (R0)