Optimal management of hepatorenal syndrome in patients with cirrhosis

Hepatorenal syndrome (HRS) is a functional renal failure that often occurs in patients with cirrhosis and ascites. 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. There are 2 different types of HRS. Type 1 HRS, which is often precipitated by a bacterial infection, especially spontaneous bacterial peritonitis, is characterized by a rapidly progressive impairment of renal function. Despite its functional origin, the prognosis of type 1 HRS is very poor. 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. New treatments (vasoconstrictors plus albumin, transjugular portosystemic shunt, and molecular adsorbent recirculating system), which were introduced in the past 10 years, are effective in improving renal function in patients with HRS. Among these treatments vasoconstrictors plus albumin can also improve survival in patients with type 1 HRS. Thus, this therapeutic approach has changed the management of this severe complication in patients with advanced cirrhosis.

Beyond Milan criteria--chances and risks of expanding transplantation criteria for HCC patients with liver cirrhosis

Orthotopic liver transplantation (OLT) is, apart from resection, one important curative treatment for hepatocellular carcinoma (HCC) in liver cirrhosis, and especially attractive because it eliminates both the tumor and the underlying liver disease. The application of restrictive inclusion criteria for OLT in HCC patients resulted in favorable long-term recurrence-free survival. These criteria, however, exclude a subgroup of patients which, despite advanced tumor size, demonstrate an acceptable outcome. As a consequence, expansion of the strict Milan criteria has been discussed. However, this will also deteriorate the average outcome of OLT in HCC patients. Considering that we run short of donor organs, more sophisticated prediction models for survival after OLT for HCC patients are needed to identify patients who benefit best from OLT. Neoadjuvant treatment that is frequently applied as a bridging technique for patients on the waiting list for OLT could provide useful information on tumor behavior to better predict the risk of post-OLT tumor recurrence. This might also allow expansion of the Milan criteria to patients with good response to downstaging methods without negatively affecting post-OLT survival. Furthermore, alternative scoring systems have been suggested to identify HCC patients that might still benefit from resection instead of OLT, and molecular tools are being explored to provide predictive information on HCC biology. This review discusses the advantages and risks of extended inclusion criteria for OLT and the currently available data on alternative prediction models and bridging methods in HCC patients.

The evaluation of renal function and disease in patients with cirrhosis

The MELD score has shown that, besides markers of liver function, serum creatinine has a strong prognostic value in cirrhosis. However, even though creatinine has a good prognostic value, it is an inaccurate marker of renal function in cirrhosis. Creatinine and creatinine-based equations tend to overestimate glomerular filtration rate (GFR), and creatinine clearance from timed urine collection also overestimates GFR. Hence, clearance of exogenous markers such as iohexol remains the only reliable method for assessing precisely GFR in cirrhosis. Whereas these investigations are limited by their costs and complexity, and they can hardly be repeated at short intervals, serum cystatin C could be an alternative, although it needs further validation. Accurate markers and/or specific equations are therefore still needed to assess GFR in cirrhotic patients. Pre-renal failure and hepatorenal syndrome (HRS) are the main causes of acute renal failure in cirrhosis. Both result from decreased renal blood flow and both can result in acute tubular necrosis. HRS is not always fully reversible with liver transplantation possibly due to underlying chronic kidney damage. A number of cirrhotic patients with acute renal failure may also have chronic kidney damage ("acute-on-chronic renal failure"); furthermore, cirrhotic patients frequently have co-morbidities such as diabetes that may result in chronic impairment in renal function. Since conventional urinary markers are biased in cirrhosis, a biopsy is the only way to document and quantify renal lesions; moreover, transvenous route should be preferred to percutaneous route. In candidates for transplantation, attention should therefore be focused on vascular lesions which may represent a risk factor for nephrotoxicities induced by calcineurin-inhibitors.

Serum cystatin C is a potential endogenous marker for the estimation of renal function in male gout patients with renal impairment

Serum creatinine level is the most commonly used indices for assessment of glomerular filtration rate (GFR), even though these indices have been shown to have some limitations in clinical practice. We investigated the diagnostic efficacy of serum cystatin C compared to that of serum creatinine levels and identified the relating factors associated with changes in serum cystatin C levels in gout patients with renal impairment. A total of 68 gouty patients with renal impairment were enrolled in this study. Diagnostic efficacy of serum cystatin C levels was evaluated through non-parametric receiver operating characteristic (ROC) analysis. The risk factors for changes in serum cystatin C levels were confirmed using multivariate regression analysis. With 24-hr urine creatinine clearance (Ccr) as the reference for GFR, 1/cystatin C (r=0.702, P<0.001) showed a significantly higher correlation with Ccr than 1/creatinine (r=0.665, P<0.001). Multivariate correlation analysis demonstrated that the clinical parameters for increased serum cystatin C are a higher stage of chronic kidney disease, older age, use of allopurinol, and lower high density lipoprotein-cholesterol. The area under the curve (AUC) at ROC plots identified that of serum cystatin C was significantly greater than that of serum creatinine (AUC 0.804 of cystatin C and AUC 0.745 of creatinine). The study suggests that serum cystatin C is a reliable endogenous marker for the assessment of renal function or GFR in gout patients with renal impairment.

Therapeutic effects of matrine on primary and metastatic breast cancer

Matrine, one of the main components extracted from a traditional Chinese herb, Sophora flavescens Ait, has displayed anti-cancer activity in several types of cancer cells. This study aims to evaluate the therapeutic benefits of matrine on primary and metastatic breast cancer. Matrine inhibited the viability of and induced apoptosis in human MCF-7 and mouse 4T1 breast cancer cells in a dose-dependent manner in vitro as shown by MTT assay, flow cytometry and laser scanning confocal microscopy. Administration of matrine inhibited the growth of primary tumors and their metastases to lungs and livers, in a dose-dependent manner, in a highly metastatic model of 4T1 breast cancer established in syngeneic Balb/c mice. Tumors from matrine-treated mice had a smaller proliferation index, shown by immunostaining with an anti-Ki-67 antibody, a greater apoptosis index, shown by TUNEL-staining, and a less microvessel density, shown by immunostaining with an anti-CD31 A antibody, compared to the controls. Western blot analysis of tumoral homogenates indicated that matrine therapy reduced the ratio of Bcl-2/Bax, downregulated the expressions of VEGF and VEGFR-2, and increased the activation of caspase-3 and caspase-9. This study suggests matrine may be a potent agent, from a natural resource, for treating metastatic breast cancer because of its anti-apoptotic, anti-proliferative and anti-angiogenic activities.

Outcome of patients with hepatorenal syndrome type 1 after liver transplantation: Hangzhou experience

BACKGROUND

Patients with hepatorenal syndrome (HRS) type 1 have an extremely poor prognosis. Liver transplantation (LT) is the only treatment that can cure terminal stage liver disease and reverse HRS. However, the data showing the impact of LT on patients with HRS type 1 are limited.

METHODS

The outcome and prognostic factors of 32 patients with HRS type 1 receiving LT were investigated. The natural course of renal recovery and the efficacy of continuous post-LT veno-veno hemodialysis (CVVH) were also evaluated.

RESULTS

Overall patient mortality was 34.4% (11/32), with eight patients died during the first month after LT. Scoring model was based on independent prognostic factors for the model end-stage liver diseases (MELD) (risk ratio=1.169) and serum sodium (risk ratio=0.769). High MELD score (>36) or low serum sodium (< or =126 mEq/L) or both were associated with reduced patient survival. HRS was resolved in 30 patients (median time, 24 days). Eight patients received post-LT CVVH. The need for CVVH was associated with higher pretransplant serum creatinine, longer duration of HRS, more pretransplant CVVH, more intraoperative blood products infusion, lower intraoperative urine output, and higher serum creatinine at 1 week posttransplant. However, serum creatinine at 1 month posttransplant and patient survival did not differ significantly between patients with and without CVVH.

CONCLUSION

Patients developing HRS type 1 in the absence of high MELD score and low serum sodium would benefit from LT.

Cystatin C: current position and future prospects

Cystatin C is a low-molecular-weight protein which has been proposed as a marker of renal function that could replace creatinine. Indeed, the concentration of cystatin C is mainly determined by glomerular filtration and is particularly of interest in clinical settings where the relationship between creatinine production and muscle mass impairs the clinical performance of creatinine. Since the last decade, numerous studies have evaluated its potential use in measuring renal function in various populations. More recently, other potential developments for its clinical use have emerged. This review summarises current knowledge about the physiology of cystatin C and about its use as a renal marker, either alone or in equations developed to estimate the glomerular filtration rate. This paper also reviews recent data about the other applications of cystatin C, particularly in cardiology, oncology and clinical pharmacology.

Hepatoprotective effects of marine and kuhuang in liver transplant recipients

We aimed to assess the effects of traditional Chinese medicine; marine (MT) and kuhuang (KH), either alone or in combination, on the early graft function of the recipients and overall patient survival rate after liver transplantation (LT) by using diammonium glycyrrhizinate (DG) as a positive control. A total of 151 subjects undergoing LT were included in this prospective study. According to the different regimens given in the first two post-transplant weeks, they were divided into DG group (n = 49), DG + KH group (n = 36), MT group (n = 42) and MT + KH group (n = 24). The graft function in the early post-transplant period and patient survival rate were examined. During the first two post-transplant weeks, there was no significant difference in total bilirubin, alanine transaminase, aspartate transaminase, serum creatinine, and prothrombin time between MT group and DG group. Patient survivals in these two groups were also similar. Compared to DG group, DG + KH group showed a significantly lower total bilirubin value on post-transplant day 5 (3.2 +/- 2.1 mg/dL vs. 5.7 +/- 5.6 mg/dL, p < 0.01) and day 7 (2.8 +/- 1.8 mg/dL vs. 5.8 +/- 6.1 mg/dL, p < 0.01), and higher patient survival. There was no significant difference between DG + KH group and MT + KH group. In conclusion, MT provides an alternative to DG after LT. The combination of MT and KH is highly effective in decreasing the total blirubin in the early post-transplant period and improving patient survival.

Renal dysfunction in the perioperative liver transplant period

PURPOSE OF REVIEW

Acute kidney failure in the perioperative liver transplant recipients results in an increased hospital length of stay, acute rejection, infection rate and overall mortality. Thus, it is of great importance to be able to recognize, prevent and treat kidney injury.

RECENT FINDINGS

Immediate post liver transplant kidney dysfunction is increased in those with pretransplant kidney failure, hepato-renal syndrome, intraoperative hypotension, intraoperative hypovolemia, aprotinin use and those requiring transfusion of more units of blood products or needing to return to the operating room.

SUMMARY

To date, avoiding risky clinical situations, maintaining homeostasis and a multidisciplinary approach to care have been reasonable approaches to decrease the incidence of postoperative acute kidney injury.

Analysis of liver transplantation outcome in patients with MELD Score > or = 30

Since July 2006, the liver graft allocation has been changed from the waiting time to the Model for End-stage Liver Disease (MELD), prioritizing the sickest patients, who have a higher risk of dying on the waiting list, and sometimes in such poor clinical condition that it compromises transplantation outcomes. The aim of this study was to analyze the impact of a MELD score > or = 30 on 30-day survival after liver transplantation (OLT). We prospectively collected the data on 178 liver transplants on 163 patients performed from March 2003 to August 2007. The subjects were divided in two groups according to their MELD scores: group 1, MELD > or = 30 (n = 15) and group 2, MELD < 30 (n = 96). The groups were compared with regard to hospital and intensive care unit (ICU) length of stay, intraoperative blood products transfusion, early survival (30 days), and need for retransplantation. We excluded, patients with prioritization criteria, those receiving extra points for any special situation, and six other patients without significant data for MELD calculation (of whom only one has died after transplantation). Patients under a "special situation" were those with hepatocelular carcinoma, hepatopulmonary syndrome, and metabolic diseases, who initially received a MELD/PELD score 20, and 24, and 29. The mean MELD score at group I was 34 (range, 30 to 42), and for group II it was 16 (range, 6 to 29). Group I displayed a mean hospital length of stay of 24 days (4 to 155), with 12.60 days (ranges, 1 to 103) in the ICU versus 15.55 (range, 1 to 48) and 5.13 (range, 1 to 45) days, respectively, for group II. The need for blood component transfusions were greater in group I; 25.28% of patients in group II did not receive any transfusion during the entire inpatient period. There were nine retransplants in group II, and none in group I. The 30-day survivals were 93.3% for group I and 84.37% for group II. Besides the increased complexity of these sickest patients, there was no negative impact on early survival rates.