Results of pretransplant treatment of hepatorenal syndrome with terlipressin

Abstract

Hepatorenal syndrome (HRS) is a dreaded complication of end-stage liver disease. The best treatment option for HRS is liver transplantation (LT) in suitable candidates. Pretransplant care of HRS is of utmost importance in order to secure a good posttransplant outcome. We review the advances during the last year in the diagnosis and management of HRS in candidates who are awaiting liver transplantation. New attempts at defining renal failure in cirrhosis using the Acute Kidney Injury (AKI) definition have been proposed, as this definition has the potential advantage of detecting earlier phases of kidney dysfunction. Patients who undergo liver transplantation with acute tubular necrosis recover renal function more slowly than those with HRS and have a higher incidence of chronic kidney disease at all time points after liver transplantation. Vasoconstrictor drugs, particularly terlipressin, are effective for the management of HRS; however, noradrenaline is a good choice if terlipressin is not available. Long-term treatment of HRS with vasoconstrictors until liver transplantation in those patients with HRS recurrence after the first treatment is beneficial as a bridge to liver transplantation. Data from the cohorts of patients treated with vasoconstrictors (terlipressin and midodrine) indicate that liver transplantation offers a clear survival benefit to patients with HRS regardless of prior therapy with these drugs. Ongoing advances in the management of patients with HRS before liver transplantation indicate that vasoconstrictors plus albumin should be offered to all suitable candidates. Liver transplantation remains the best treatment option for HRS.