Title:Pathophysiology, Diagnosis and Clinical Management of Hepatorenal Syndrome: From Classic to New Drugs
Volume: 12
Issue: 1
Author(s): Biagio Barbano, Liborio Sardo, Antonietta Gigante, Maria Ludovica Gasperini, Marta Liberatori, Gianluca Di Lazzaro Giraldi, Antonio Lacanna, Antonio Amoroso and Rosario Cianci
Affiliation:
Keywords:
Acute kidney injury, hepatorenal syndrome, refractory ascites, terlipressin, vaptans, vasoconstrictors.
Abstract: Advanced cirrhosis is frequently associated with renal dysfunction. Hepatorenal syndrome (HRS) is characterized
by the occurrence of kidney injury in cirrhotic patients in the absence of other identifiable causes. HRS is classified
in 2 different types. Type 1 is characterized by acute renal failure and rapid functional deterioration of other organs, usually
related to a precipitating event. Type 2 is characterized by slowly progressive renal failure and refractory ascites. Advanced
liver disease induces the progression of hemodynamic alterations such as arterial vasodilation of splanchnic circulation
and impairment of cardiac function. The resulting ineffective circulating blood volume promotes the activation of
both the renin-angiotensin-aldosterone and sympathetic nervous system, by an increase of antidiuretic hormone activity, in
an attempt to restore volemia. Despite fluid retention, ascites and dilutional hyponatremia, renal function is often initially
preserved by renal production of vasodilators. However, further insults can lead to an imbalance between systemic vasoconstriction
and local renal vasodilation, resulting in progressive renal failure. Over the last decade, clinical strategies to
prevent HRS have been improved by a better understanding of the natural history of renal failure in cirrhosis, resulting in
a reduction of HRS prevalence in cirrhotic patients. Vasoconstrictor drugs may improve renal function, but the effect on
mortality has not yet been established. Vaptans, nonpeptide vasopressin receptor antagonists, may also reduce hyponatraemia
and ascites, even if the clinical effects in HRS remain unknown. This review updates the pathophysiology, diagnosis
and management of HRS.
