Renal failure is a common complication of cirrhosis and is a poor prognostic indicator. Patients with severe liver dysfunction can develop HRS, characterized by a marked reduction in renal blood flow and hemodynamic disturbances. HRS is now subdivided into 2 types. Type 1 HRS carries a worse prognosis than type 2; these patients also do worse after liver transplantation. Precipitants of HRS need to be sought out and managed early. It is also important to rule out other organic causes of renal disease that can occur in these patients. The most common precipitants are bacterial infection, gastrointestinal bleeding, and aggressive paracentesis. Antibiotic prophylaxis should be used in patients with a history of SBP and in those admitted to hospital for gastrointestinal bleeding. Any nephrotoxic drugs should be removed and volume status of the patient should be maintained. Albumin infusions may be used in patients admitted with SBP and those undergoing large-volume paracentesis. Diuretic use in patients with ascites need to be monitored, and these agents should be stopped if renal function worsens. Many treatment options are now showing promise for patients with HRS. Numerous studies have shown the benefit of terlipressin in this setting, with fewer side effects; however, there is also some evidence for the combination of midodrine and octreotide when terlipressin is not available. Intravenous albumin should be considered in adjunct. If there is no response to these therapies, TIPS or the molecular adsorbent recirculating system could be considered. Orthotopic liver transplantation is the most effective strategy for treatment of HRS. Unfortunately, some patients with HRS are not candidates for liver transplantation. For those patients who are to receive liver transplantation, their chances for survival are improved if their renal function is optimized before transplantation.
|MedGenMed Medscape General Medicine
|Published - 2004
ASJC Scopus subject areas
- General Medicine