Syndrome In Cirrhotic Patients Research Articles

The Use of Nuetrophil Gelatinase Associated Lipocalin (NGAL) as a Novel Marker in Early Diagnosis of Hepato Renal Syndrome in Advanced Cirrhotic Patients

Abstract Background Acute kidney injury (AKI) in cirrhosis, including hepatorenal syndrome (HRS), is a common and serious complication in cirrhotic patients, leading to significant morbidity and mortality. Objective To predict value of serum and urinary NGAL as an early predictor of hepatorenal syndrome in cirrhotic patients. Patients and Methods The study was conducted on 60 participants with cirrhosis child C on Child-Pugh score, each one was investigated for both Urinary and Plasma NGAL level. Randomized controlled clinical trial. This study is a prospective, random, clinical trial conducted at Kafr El Sheikh Liver Institution Results Group I had Urinary NGAL ranged from 12 - 120, with a mean value of 61.45 ± 36.17. While group II A, ranged from 211-493 with a mean value of 379 ± 72.825. And in group II B, ranged from 306- 732 with a mean value of 438.05 ± 111.26. There was statistical difference between studied groups, p value <0.001. It was found that Urinary NGAL not only good predictor for early renal affection, but also it can differentiate between HRS and non HRS AKI due to the marked difference readings of its level in groups with renal impairment. Conclusion Both Plasma and urinary NGAL levels are markedly elevated in renal affection whatever the cause, so they are highly sensitive in detecting early renal impairment. However, the rate of elevation of plasma NGAL is so close in different types of AKI so it’s not advisable to use it alone to diagnose HRS. On the other hand, Urinary NGAL show noticeable differences between degree of elevation with different causes of AKI, so it’s somehow could be a trusted diagnostic tool to diagnose HRS.

A Simple and Quick Screening Method for Intrapulmonary Vascular Dilation in Cirrhotic Patients Based on Machine Learning.

Background and AimsScreening for hepatopulmonary syndrome in cirrhotic patients is limited due to the need to perform contrast enhanced echocardiography (CEE) and arterial blood gas (ABG) analysis. We aimed to develop a simple and quick method to screen for the presence of intrapulmonary vascular dilation (IPVD) using noninvasive and easily available variables with machine learning (ML) algorithms.MethodsCirrhotic patients were enrolled from our hospital. All eligible patients underwent CEE, ABG analysis and physical examination. We developed a two-step model based on three ML algorithms, namely, adaptive boosting (termed AdaBoost), gradient boosting decision tree (termed GBDT) and eXtreme gradient boosting (termed Xgboost). Noninvasive variables were input in the first step (the NI model), and for the second step (the NIBG model), a combination of noninvasive variables and ABG results were used. Model performance was determined by the area under the curve of receiver operating characteristics (AUCROCs), precision, recall, F1-score and accuracy.ResultsA total of 193 cirrhotic patients were ultimately analyzed. The AUCROCs of the NI and NIBG models were 0.850 (0.738–0.962) and 0.867 (0.760–0.973), respectively, and both had an accuracy of 87.2%. For both negative and positive cases, the recall values of the NI and NIBG models were both 0.867 (0.760–0.973) and 0.875 (0.771–0.979), respectively, and the precisions were 0.813 (0.690–0.935) and 0.913 (0.825–1.000), respectively.ConclusionsWe developed a two-step model based on ML using noninvasive variables and ABG results to screen for the presence of IPVD in cirrhotic patients. This model may partly solve the problem of limited access to CEE and ABG by a large numbers of cirrhotic patients.

S1150 Predictors of Development of Hepato-Renal Syndrome in Cirrhotic Patients With Acute Kidney Injuries

INTRODUCTION: Acute kidney injury (AKI) is a serious complication of liver cirrhosis with high mortality rates. Hepato-renal syndrome (HRS) is the cause of AKI in approximately 10–20% of cirrhotic patients while prerenal AKI and acute tubular necrosis are more common causes. Correct differentiation is imperative as management and outcomes differ substantially. Diagnosis of HRS is often delayed requiring 48 hours of attempts at volume expansion before a definitive diagnosis can be made. Mortality associated with HRS is substantially higher compared to other causes of AKI and treatment requires a timely multidisciplinary approach. We hypothesize that the risk of HRS can be predicted based on patient's baseline clinical characteristics and laboratory values at the time of development of AKI. We aim to describe potential variables associated with HRS in cirrhotic patients presenting with AKI. METHODS: This is a retrospective analysis of 235 cirrhotic patients admitted with AKI to Staten Island University Hospital, NY. We collected demographics, medical history, vital signs, laboratory data, medications, procedures during hospital stay and outcomes. Patients with a diagnosis of HRS were identified as a separate group. We performed a bivariate analysis to determine variables associated with the development of HRS. RESULTS: Patients were predominantly males (61%) and Caucasians (55%). Mean age of our cohort was 66 (±13) years. Alcoholic liver cirrhosis was the most common etiology (52%). The mean Charleson Comorbidity Index (CCI) score and MELD score were 5 and 18, respectively. Ascites was the most encountered clinical sign of portal hypertension (21%). 16% of patients received albumin and 25 patients (11%) were diagnosed with HRS. Death occurred in 11% of patients. Variables that were statistically significantly associated with the diagnosis of HRS included alcoholic cirrhosis, higher CCI and MELD scores, clinical signs of portal hypertension (history of hepatic encephalopathy and/or ascites), lower platelet count and sodium level, higher bilirubin and INR. Mortality in patients with HRS was 40%. CONCLUSION: HRS-AKI is a diagnosis of exclusion and is often difficult to establish. We identified clinical variables and laboratory data that can guide clinicians through an early diagnosis of HRS to allow for a better targeted approach in an attempt to lower mortality. We intend on developing a predictive model for the diagnosis of HRS based on the identified associated variables identified in this study.Table 1.: Clinical characteristics and outcomes of cirrhotic patients admitted with Acute Kidney injuryTable 2.: Variables associated with the development of HRS in cirrhotic patients admitted with Acute Kidney Injury

Albumin for Cirrhotic Patients with Infections Unrelated to Spontaneous Bacterial Peritonitis

Previous studies have shown that intravenous albumin treatment improves survival and reduces risk for type 1 hepatorenal syndrome in cirrhotic patients

Correlations of MMP-2 and MMP-9 gene polymorphisms with the risk of hepatopulmonary syndrome in cirrhotic patients: A case-control study

Hepatopulmonary syndrome (HPS) increases the mortality of patients who suffered from liver cirrhosis, especially patients plagued by severe hypoxemia. Gene polymorphisms are reported to be related to the risk of HPS in cirrhotic patients. Thus, our study aims to elucidate the correlation between MMP-2 and MMP-9 gene polymorphisms and HPS in cirrhotic patients. A total of 152 cirrhotic patients suffering from HPS as well as another 152 cirrhotic patients without HPS were recruited. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was performed for MMP-2 and MMP-9 gene polymorphisms and logistic regression analysis for the relationship between clinicopathological features and HPS occurrence in cirrhotic patients. There were significant differences in genotype and allele frequency of MMP-2 rs243865 and MMP-9 rs3918242 polymorphisms between the HPS and control groups. CC/CT genotype and C allele of MMP-2 rs243865 polymorphism as well as CC/TT genotype and T allele of MMP-9 rs3918242 polymorphism increased the risk of HPS in cirrhotic patients. Genotypes of rs243865 and rs3918242 polymorphisms had remarkable correlations with spider nevi, clubbed fingers (toes), transaminase elevation, portal vein width, esophageal varices, Child-Pugh classification and partial pressure of arterial oxygen (PaO2). Logistic regression analysis showed that rs243865 and rs3918242 polymorphisms, spider nevi, clubbed fingers (toes), esophageal varices, and Child-Pugh classification were closely associated with the occurrence of HPS in cirrhotic patients. Our findings demonstrate that MMP-2 rs243865 polymorphism and MMP-9 rs3918242 polymorphism can increase the risk of HPS occurrence in cirrhotic patients, which provides a potential target for prevention of HPS in cirrhotic patients.

Interlobar Artery Resistive Index predicts Acute-on-Chronic Liver Failure Syndrome in Cirrhotic Patients withAcute Decompensation.

Patients with acutely decompensated (AD) cirrhosis are at risk for developing acute-on-chronic liver failure (ACLF) syndrome. This syndrome is associated with a high short-term mortality rate. The aim of our study was to identify reliable early predictors of developing ACLF in cirrhotic patients with AD. We assessed 84 cirrhotic patients admitted for AD without ACLF on admission. We performed routine blood testing and detailed ultrasound Doppler studies of systemic arteries and mayor abdominal veins and arteries. We also calculated liver-specific and intensive care unit predictive scores. The area under the ROC curve (AUROC) was calculated for all variables that were significantly different between patients who developed ACLF and those who did not. Sensitivity, specificity, positive and negative predictive values, as well as diagnostic accuracy predicting the short-term development of ACLF were determined. of the 84 patients, 23 developed ACLF whereas 61 did not. In the univariate analysis, serum levels of creatinine and urea, prothrombin time ratio, MELD score, portal vein and femoral artery flow velocity as well as the renal and interlobar artery resistive indices (RI) were associated with the short-term development of ACLF. However, only interlobar artery RI had independent predictive value in the multivariate analysis. The AUROC value for RI of the interlobar arteries was 0.9971. On the first day of admission, ultrasound measurement of the RI of the interlobar arteries recognizes with high predictive accuracy those cirrhotic patients admitted with AD who will develop ACLF during hospital admission.

Hepatopulmonary Syndrome: A Commonly Missed Complication of Chronic Liver Disease

Case of a 65-year-old man with medical history of hypertension and cirrhosis secondary to Hepatitis C, who was initially consulted to gastroenterology service due to intermittent loose and blood tinged stools for which he was scheduled for a colonoscopy. On the procedure day he was found with a peripheral O2 saturation of 88% at room air, improving to 99% with nasal cannula. Hepatopulmonary syndrome was suspected, but prior to starting work up, patient was admitted under Internal Medicine service due to progressive dyspnea and multiple syncopal episodes. During admission a pulmonary scintigraphy was performed reporting abnormal tracer concentration in several extrapulmonary organs, highly suggestive of a right-to-left shunt. Pulmonary service evaluated patient and noted that after exercise testing disease severity interpretation had changed from moderate to very severe. Upon discharge patient was requiring continuous oxygen supplementation. Subsequently, cardiology service performed contrast echocardiogram with agitated saline in which contrast was seen to enter the left atrium 6 beats after first entering the right atrium, confirming hepatopulmonary syndrome. Patient was referred to the liver transplant center, where he was placed on transplant list with MELD exception. Hepatopulmonary syndrome is caused by a defect in arterial oxygenation due to pulmonary vascular dilatation in the setting of liver disease. Contrast-enhanced transthoracic echocardiography with saline is the most practical method to detect pulmonary vascular dilatation. Dyspnea at exertion or at rest, although non-specific, is the most common presenting finding. Prevalence of this syndrome ranges from 5%-32% although no prospective studies are available. Liver transplantation is the only treatment with documented success. This case serves to illustrate the importance of maintaining a keen eye on subtle symptoms that a patient with chronic liver disease may develop and which may usually be put off as part of the disease per se. Patients with chronic liver disease should have at least peripheral oximetry obtained in each routine visit and arterial blood gases should be obtained if there is dyspnea. Early suspicion of hepatopulmonary syndrome in cirrhotic patients is important in order to provide them a prompt work up which will definitely expedite the liver transplant process before the syndrome progresses and excludes them as candidates.

Mean platelet volume as a novel predictor of systemic inflammatory response in cirrhotic patients with culture-negative neutrocytic ascites.

To identify a mean platelet volume (MPV) cutoff value which should be able to predict the presence of bacterial infection. An observational, analytic, retrospective study. We evaluated medical records of cirrhotic patients who were hospitalized from January 2012 to January 2014 at the Gastroenterology Department of "Hospital General de México Dr. Eduardo Liceaga", we included 51 cirrhotic patients with ascites fluid infection (AFI), and 50 non-infected cirrhotic patients as control group. Receiver operator characteristic curves were used to identify the best cutoff value of several parameters from hematic cytometry, including MPV, to predict the presence of ascites fluid infection. Of the 51 cases with AFI, 48 patients (94.1%) had culture-negative neutrocytic ascites (CNNA), 2 (3.9%) had bacterial ascites, and one (2%) had spontaneous bacterial peritonitis. Infected patients had greater count of leucocytes and polymorphonuclear cells, greater levels of MPV and cardiac frequency (P < 0.0001), and lower mean arterial pressure compared with non-infected patients (P = 0.009). Leucocytes, polymorphonuclear count, MPV and cardiac frequency resulted to be good or very good predictive variables of presence of AFI in cirrhotic patients (area under the receiving operating characteristic > 0.80). A cutoff MPV value of 8.3 fl was the best to discriminate between cirrhotic patients with AFI and those without infection. Our results support that MPV can be an useful predictor of systemic inflammatory response syndrome in cirrhotic patients with AFI, particularly CNNA.

QT interval prolongation: a risk factor for development of hepatorenal syndrome in cirrhotic patients with acute variceal bleeding.

This study aimed to assess whether QT interval prolongation is an independent risk factor for development of hepatorenal syndrome (HRS) in cirrhotic patients with acute variceal bleeding. 78 consecutive cirrhotic patients with acute variceal bleeding were included in the study. All patients were evaluated before bleeding (T0), during bleeding (T1) and 6 weeks later (T2). HRS developed in 14 (17.9%) patients. QT corrected by heart rate (QTc) prolonged at T1, returning towards baseline at T2 (mean ± SD; from 424.0 ± 10.2 to 461.2 ± 17.6 to 426.1 ± 8.8ms, P < 0.001). At T1, patients who developed HRS had longer QTc (P = 0.017) and lower serum sodium (P = 0.039). QTc and serum sodium independently predicted HRS; the best cut-off values were QTc > 468 ms and sodium < 120 mEq/L. Patients on beta-blocker were found to have significant risk for developing HRS (p = 0.040). Based on these three factors, the risk for HRS was nil for patients without risk factors; 6.1%, 11.1%, and 83.3% for those with one, two or three risk factors, respectively (p < 0.001). Acute variceal bleeding causes further prolongation of QTc in cirrhosis. The combination of beta-blocker, QTc interval and serum sodium can aid in early detection of patients at increased risk of developing bleed-precipitated HRS, thus improving their outcome.

Urinary neutrophil gelatinase-associated lipocalin as a biomarker for the diagnosis of hepatorenal syndrome in cirrhotic patients

PurposeThe aim of the study was to assess the usefulness of urinary neutrophil gelatinase-associated lipocalin (uNGAL) as a biomarker for hepatorenal syndrome (HRS) in patients with cirrhosis.Patients and methodsEighty-two cirrhotic patients were enrolled in this study. Urinary levels of NGAL were measured using enzyme-linked immunosorbent assay. Ten normal healthy individuals were enrolled as a control group. Group I included 15 cirrhotic patients with normal kidney function. Group II included 52 cirrhotic patients with acute impaired kidney function: 21 with prerenal azotemia, 22 with HRS, and nine with intrinsic acute kidney injury (iAKI). Group III included 15 cirrhotic patients with chronic impaired kidney function. Group IV included 10 healthy normal individuals as control.ResultsIn HRS, uNGAL was significantly different from patients with either iAKI or prerenal azotemia. uNGAL levels in patients with prerenal azotemia were low and equivalent to levels in patients with normal kidney function and chronic kidney disease. uNGAL elevation was more prominent in type 1 than in type 2. Serum creatinine was significantly higher in patients with iAKI compared with those with normal kidney function and chronic kidney disease but was statistically similar to those with prerenal azotemia and HRS. Patients with HRS had a significantly higher level of serum creatinine than those with prerenal azotemia, but the level was similar to patients with iAKI. Fractional excretion of sodium was significantly higher in patients with iAKI than in patients with either HRS or prerenal azotemia.ConclusionuNGAL levels may be useful in the differential diagnosis of HRS from other causes of acute impairment of kidney function in cirrhosis.

Budd-Chiari Syndrome Diagnosed by Maximal Intensity Projection and Minimum Intensity Projection of CT Images Prior to Liver Transplantation

Introduction: Diagnosis of Budd-Chiari syndrome in cirrhotic patients is usually not easy. We reported a patient with Budd-Chiari syndrome that was detected by Maximum Intensity Projection (MIP) and Minimum Intensity projection (MinIP) from CT images. Case presentation: A 55 year-old man with chronic hepatitis B and a past history of alcoholism was diagnosed to be compensated liver cirrhosis. He received left lateral sectionectomy for hepatic epitheloid angiomyolipoma (4.6×3.5×3.3 cm) and also splenectomy on July 25, 2011. Decompensation of liver with intractable ascites and jaundice occurred 4 months later. Liver transplantation was planned for him and relevant examinations were arranged. Budd-Chiari was discovered incidentally. From venous phase of enhanced CT images, reformed images with Maximum Intensity Projection (MIP), one of volume-rendering techniques, demonstrated enhanced right hepatic vein and no opacification of middle hepatic vein (MHV). Reformed images with Minimum Intensity Projection (MinIP), reveals hypoenhancement of the middle hepatic vein as dark branches on the background of enhanced liver parenchyma. The pictures suggested of thrombosis of MHV. He received living donor liver transplantation with right lobe graft of his daughter on Dec. 1, 2011. Thrombosis in his middle hepatic vein with protruding thrombosis in inferior vena cava was noted during transplantation surgery. The postoperative course was uneverful. Microscopically, his liver reveals micronodular cirrhosis with mixed inflammation in portal area. Some liver lobule exhibited congestion and sinusoid dilatation, compatible with venous occlusion clinically. Conclusion: MIP and MinIP of CT images are helpful in the diagnosis of Budd-Chiari syndrome. Invasive procedures, such as angiography, can be avoided.

Reversal of hepatorenal syndrome in cirrhotic patients with terlipressin plus albumin. First experience in Mexico

Introduction. Type 1 hepatorenal syndrome (HRS) is a functional renal failure that complicates end-stage cirrhosis. The vasopressin analogue terlipressin has been associated with improved renal function in patients with type 1 HRS.Aim. To evaluate the effectiveness of an infusion of terlipressin plus albumin in reversing type 1 HRS, its tolerability, and its adverse effects.Methods. Thirteen consecutive patients with cirrhosis and type 1 HRS were included in the study. All patients received terlipressin plus albumin as treatment for HRS. The patients were divided in two groups. Group 1 contained eight patients in whom HRS was reversed with treatment, who were classified as responders. Group 2 contained five patients who were nonresponders.Results.Sixty-one percent of the patients who received terlipressin plus albumin responded to therapy and underwent HRS reversal. In two patients, treatment with terlipressin was stopped because of adverse events. No relapse of HRS after terlipressin withdrawal was observed in this study.Conclusion.The rate of successful treatment with terlipressin plus albumin was 61%, similar to that in previously reported controlled trials. However, this is the first experience reported in Mexico. A cardiovascular evaluation is required before the start of treatment with terlipressin. This treatment appears to be an effective therapy for improving renal function in patients with type 1 HRS.

The systemic inflammatory response syndrome in cirrhotic patients: Relationship with their in-hospital outcome

Some evidence suggests that the systemic inflammatory response syndrome (SIRS) contributes to the poor outcome of cirrhotic patients. We studied 141 cirrhotic patients consecutively admitted to a tertiary referral centre assessing prevalence of SIRS and its relationship with in-hospital outcome. Presence of SIRS was assessed on admission and during hospital stay. Main clinical outcomes were death and development of portal hypertension-related complications. Thirty-nine patients met SIRS criteria. SIRS was present on admission in 20 of 141 patients (14.1%), whereas it occurred during hospital stay in 19 of 121 (15.7%). SIRS was correlated with bacterial infection at admission (p=0.02), jaundice (p=0.011), high serum creatinine levels (p=0.04), high serum bilirubin levels (p=0.002), high international normalized ratio (p=0.046), high model of end-stage liver disease (MELD) score (p=0.001), and high SOFA score (p=0.003). During a follow-up of 14+/-8 days, 16 patients died (11%), 7 developed portal hypertension-related bleeding (5%), 16 hepatic encephalopathy (11%), and 5 hepatorenal syndrome type-1 (3.5%). SIRS was correlated both to death (p<0.001) and to portal hypertension-related complications (p<0.001). On multivariate analysis, SIRS and MELD were independently associated with death. SIRS frequently occurs in patients with advanced cirrhosis and is associated with a poor outcome.

Clinical features of hepatopulmonary syndrome in cirrhotic patients

To evaluate the frequency, clinical and paraclinical features of hepatopulmonary syndrome (HPS) and to determine their predictive values in diagnosis of this syndrome in patients in Iran. Fifty four cirrhotic patients underwent contrast enhanced echocardiography to detect intrapulmonary and intracardiac shunts by two cardiologists. Arterial blood oxygen, O(2) gradient (A-a) and orthodoxy were measured by arterial blood gas (ABG) test. The patients positive for diagnostic criteria of HPS were defined as clinical HPS cases and those manifesting the intrapulmonary arterial dilation but no other criteria (arterial blood hypoxemia) were defined as lHPS cases. HPS frequency, sensitivity, positive and negative predictive values of clinical and paraclinical features were studied. Ten (18.5%) and seven (13%) cases had clinical and subclinical HPS, respectively. The most common etiology was hepatitis B. Dyspnea (100%) and cyanosis (90%) were the most prevalent clinical features. Dyspnea and clubbing were the most sensitive and specific clinical features respectively. No significant relationship was found between HPS and splenomegaly, ascites, edema, jaundice, oliguria, and collateral veins. HPS was more prevalent in hepatitis B. PaO(2)< 70 and arterial-alveolar gradient had the highest sensitivity in HPS patients. Orthodoxy specificity was 100%. Clubbing with positive predictive value (PPV) of 75% and dyspnea with negative predictive value (NPV) of 75% are the best clinical factors in diagnosis of HPS syndrome. PaO(2)< 70 and P (A-a) O(2)> 30 and their sum, are the most valuable negative and positive predictive values in HPS patients.

Le syndrome hépatorénal chez le patient cirrhotique

Hepatorenal syndrome is a particular form of functional renal failure which may develop in patients with liver cirrhosis. On a clinical standpoint, precise diagnostic criteria have been established to clearly define this entity, whereas recent advances in the understanding of the biology of vasoactive mediators and the physiology of microcirculation have allowed to better anticipate its pathophysiological mechanisms. During the course of cirrhosis, sinusoidal portal hypertension leads to splanchnic and systemic vasodilation, responsible for a reduction of effective arterial blood volume. As a result, a state of intense renal vasoconstriction develops, leading to renal failure in the absence of any organic renal disease. At this stage, liver transplantation is the only definitive therapy able to reverse renal dysfunction. In recent years, innovative therapies have shown promise to prolong survival in patients with hepatorenal syndrome, including the administration of analogs of vasopressin (mainly terlipressin), the insertion of transjugular intrahepatic portosystemic shunts and the use of novel techniques of dialysis. On a preventive viewpoint, several simple measures have been shown to reduce the risk of hepatorenal syndrome in cirrhotic patients, including the appropriate use of diuretics, the avoidance of nephrotoxic drugs, the prophylaxis of spontaneaous bacterial peritonitis and optimal fluid management in patients undergoing large volume paracentesis.

Nitric oxide and portal hypertension: a nitric oxide-releasing derivative of ursodeoxycholic acid that selectively releases nitric oxide in the liver

Portal hypertension, a common consequence of chronic liver diseases, is directly responsible for most complications of cirrhosis. In liver microcirculation, nitric oxide is considered a major fine tuner of vascular tone by counterbalancing vasoconstrictors (sympathetic nervous activity, the renin-angiotensin system, and endothelin-1) in normal and cirrhotic livers. The deficiency of endothelial nitric oxide release is a key factor in the hemodynamic abnormalities associated with the dynamic component of portal hypertension. Conventional nitric oxide donors release nitric oxide into the blood stream, causing systemic hypotension and progression of vasodilatory syndrome in cirrhotic patients. NCX1000 is a nitric oxide-releasing derivative of ursodeoxycholic acid-derived compounds, being capable of selectively releasing nitric oxide into the liver circulation. Administration of NCX1000 to portal hypertensive rats decreases intrahepatic resistance providing a novel therapy for the treatment of portal hypertension.

Frequency of hepato-pulmonary syndrome in cirrhotic patients

Frequency of hepato-pulmonary syndrome in cirrhotic patients

Effect of terlipressin (Glypressin) on hepatorenal syndrome in cirrhotic patients: results of a multicentre pilot study.

Hepatorenal syndrome (HRS) is a severe complication of cirrhosis, leading to death in more than 90% of cases in the absence of liver transplantation. Several treatments have been attempted as a bridge to liver transplantation. Among such treatments, terlipressin has been studied in several reports, two prospective pilot studies and a double-blind, short-term, controlled haemodynamic study. Promising results have been shown with this drug. The purpose of this multicentre retrospective study was to evaluate the effects of terlipressin on renal function and survival of patients with HRS. Eighteen patients recruited in three liver units with type 1 HRS in 16 cases and type 2 HRS in two cases were given 4 mg/day terlipressin (range 1.5-12) for 7 days (range 2-16). Electrolytes, renal function, mean urinary output, natriuresis, liver function tests, and tolerance of the treatment were monitored regularly. A total of 13/18 (72%) patients responded with a mean decline in serum creatinine ranging from 31 to 75% from day 0 to day 5. Eight of these 13 patients had a normal serum creatinine level at day 5. Liver function tests remained unaffected by terlipressin administration. Three local necrosis complications were noted in patients receiving terlipressin continuously via an infusion pump. Two responder patients survived: one of these underwent orthotopic liver transplantation with a follow-up of 24 months; the other is alive with a follow-up of more than 36 months. Patients who responded to terlipressin had lower baseline serum bilirubin and significantly higher serum sodium concentrations than patients who did not respond. In this pilot study, improvement in renal function was noted in 72% of cases after administration of terlipressin, and was associated with long-term survival in two patients. Parameters associated with response to terlipressin and increased survival should be defined better in a large cohort of cirrhotic patients with HRS.

Review article: pharmacological treatment of the hepatorenal syndrome in cirrhotic patients.

Renal failure is common in patients who are dying from end-stage cirrhosis, developing in 40-80% of all patients. Where there is no anatomical or pathological cause for the renal failure, it is termed the hepatorenal syndrome. When the hepatorenal syndrome develops, it will only recover when there is some degree of improvement in liver function. Thus for most patients this will occur only after liver transplantation, although the transplantation mortality is increased in this group. Hepatorenal syndrome is a common complication of alcoholic hepatitis, and this group is unusual in that with time and abstinence, significant recovery of liver function may occur. There is therefore a need for supportive therapy to allow time for some recovery of liver function in patients with alcoholic hepatitis and hepatorenal syndrome. Similarly, patients may need support whilst waiting for liver transplantation. This article reviews the pathophysiology and treatment of hepatorenal syndrome.