Hepatorenal syndrome

Hepatorenal syndrome (HRS) is a functional renal failure that often occurs in patients with cirrhosis and ascites. Two different types of HRS have been described. Type 1 HRS develops as a consequence of a severe reduction of effective circulating volume due to both an extreme splanchnic arterial vasodilatation and a reduction of cardiac output. Type 2 HRS is characterized by a stable or slowly progressive renal failure so that its main clinical consequence is not acute renal failure, but refractory ascites, and its impact on prognosis is less negative. Liver transplantation (LT) represents the best therapeutic option in cirrhotic patients with HRS. Nevertheless, other therapeutic options were investigated as 'bridge treatments' towards orthotopic LT or for patients who cannot be candidates for LT. Several pilot studies and two randomized control studies have shown that terlipressin plus albumin improves renal function in patients with type 1 HRS. Terlipressin plus albumin can also improve short-term survival in these patients. Terlipressin was most commonly used by intravenous boluses moving from an initial dose of 0.5-1 mg every 4 h to 3 mg every 4h in cases of nonresponse. Nevertheless, there are some preliminary data showing that terlipressin given by continuous intravenous infusion is better tolerated than when it is given by intravenous boluses. The available data are sufficient to state that the use of terlipressin plus albumin has really changed the management of type 1 HRS. Nevertheless, it should be noted that recovery of renal function can only be achieved in less than 50% of patients with type 1 HRS and that the recovery of renal function may also be partial inpatients who are defined as full responders. Thus, while the optimization of this treatment should be investigated, other therapeutic options should be developed and tested as well.