Hepatorenal syndrome (HRS) is one of the common complications of advanced liver cirrhosis. The prognosis of HRS is poor. Once it progresses to HRS, the survival period of patients with liver disease will be significantly shortened, while the survival period of untreated patients will be further shortened. Therefore, early diagnosis and treatment of HRS is very important to prevent further deterioration of renal failure in patients.
This article will be based on the guidelines and consensus issued by the Chinese Society of Liver Diseases, the European Society of Liver Diseases (EASL) and the International Ascites Club (ICA), to comprehensively summarize the key contents of the diagnosis and treatment of HRS.
According to the consensus published by ICA in 2019 [1], HRS is defined as a potential kidney damage that occurs in patients with liver disease, especially cirrhosis and ascites. HRS is usually caused by liver (alcohol abuse, drugs, hepatitis) and/or extrahepatic (bacterial infection and/or bacterial translocation) factors, and its main pathogenesis may be: increased portal pressure and visceral vasodilation leading to circulatory dysfunction ( Insufficient renal blood perfusion caused by visceral vasodilation and decreased cardiac output. In recent years, it is believed that increased levels of inflammatory mediators in the circulation also play an important role.
generally believes that the essence of HRS is functional disease, but it cannot be completely ruled out that there is no underlying renal disease, especially renal tubule and renal interstitial disease. Its subtypes include hepatorenal syndrome-acute kidney injury (HRS-AKI) and hepatorenal syndrome-non-acute kidney injury (HRS-NAKI).
1. Diagnostic criteria
ICA released a consensus to revise the classification and diagnostic criteria of hepatorenal syndrome (HRS). In the 2019 standard, the latest classification standard removes the previous type 1 and type 2 HRS. The previous type 1 HRS is equivalent to HRS-AKI, and the type 2 HRS includes HRS-NAKI and acute kidney disease (AKD).
Table 1 is the diagnosis and staging criteria for acute kidney injury revised by ICA in 2019.
Table 1 Standards for diagnosis and staging of acute kidney injury
*Adapted from the guidelines of the European Association of Liver Diseases (EASL)
According to the "Guidelines for the Diagnosis and Treatment of Liver Cirrhosis" issued by the Chinese Society of Liver Diseases in 2019, the diagnostic criteria for HRS-AKI are:
( 1) Liver cirrhosis and ascites; (corresponding ICA standards are: liver cirrhosis with ascites, acute liver failure or chronic acute liver failure);
(2) meets ICA's diagnostic criteria for IKI;
(3) discontinue diuretics And according to 1 g/kg body weight to add albumin to expand blood volume treatment 48h no response;
(4) no shock;
(5) currently or recently no nephrotoxic drugs are used;
(6) no signs of renal structural damage : No proteinuria (<500>
HRS-NAKI includes hepatorenal syndrome-acute liver disease (HRS-AKD) and hepatorenal syndrome-chronic liver disease (HRS-CKD). HRS-AKD refers to: (1) Except for HRS-AKI, liver cirrhosis with or without ascites; (2) glomerular filtration rate (eGFR) <60>
2. HRS treatment
1. General treatment
bed rest, high-calorie digestible diet, close monitoring of blood pressure, urine output, and maintaining fluid balance. Monitor liver and kidney function and clinical evaluation of the complications of liver cirrhosis. Avoid excessive fluid intake to prevent fluid overload and dilutional hyponatremia.
2. Vasoconstrictor drug treatment
Vasoconstrictor drugs mainly constrict the significantly expanded visceral blood vessels in HRS patients, improve hyperdynamic circulation, and increase peripheral arterial pressureTo increase renal blood flow and eGFR.
The main vasoconstrictor drugs currently include: vasopressin and its analogs (terlipressin), α-adrenergic receptor agonists (midodrine and norepinephrine), somatostatin analogs (Octreotide) and so on.
Table 2 The vasoconstrictor drug treatment recommendations of each guideline are
3. Other treatment methods
Transjugular intrahepatic portosystemic shunt (TIPS) can improve the renal function of HRS-AKI and HRS-NAKI patients. However, patients with liver cirrhosis and ascites with HRS-AKI are generally in serious condition and often have contraindications to TIPS treatment. Therefore, HRS-NAKI, which does not respond to vasoconstrictor drug therapy and has a large amount of ascites, can be treated with TIPS. TIPS therapy is not recommended for HRS-AKI.
Blood purification therapy (artificial liver, kidney replacement therapy) can improve the renal function of some HRS-AKI patients. For HRS-AKI that does not respond to vasoconstrictor treatment and meets the criteria for renal replacement therapy, renal replacement therapy or artificial liver support system can be selected. Regardless of the response to drug therapy, liver transplantation is the best treatment option for HRS patients. The indications for combined liver and kidney transplantation are still controversial. Patients with significant chronic kidney disease or persistent AKI, including HRS-AKI patients who do not respond to drug therapy, may consider combined liver and kidney transplantation.
References:
[1] Paolo Angeli, Guadalupe Garcia-Tsao, Mitra K, et al. News in pathophysiology, definition and classification of hepatorenal syndrome: A step beyond the International Club of Ascites (ICA) consensus document [J]. Journal of Hepatology. October 2019. DOI:10.1016/j.jhep.2019.07.002
[2] Chinese Medical Association Hepatology Branch. Guidelines for diagnosis and treatment of liver cirrhosis [J]. Journal of Clinical Hepatobiliary Diseases, 2019, 35(11): 2408-2425.
[3] Angeli P, Bernardi M, Villanueva, Càndid, et al. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis[J]. Journal of Hepatology, 2018:S0168827818319664.
[4] Shi Huimin, Li Rui, Chen Hong, et al. "2018 European Society of Liver Disease Management Clinical Practice Guidelines for Patients with Decompensated Cirrhosis" [J]. Journal of Clinical Hepatobiliary Disease, 2018, 34(8):1642-1638.
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