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Calleri A, Alessandria C. Renal damage in Hepatorenal Syndrome: A still unsolved issue. Clin Res Hepatol Gastroenterol 2023; 47:102178. [PMID: 37453679 DOI: 10.1016/j.clinre.2023.102178] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/02/2023] [Accepted: 07/12/2023] [Indexed: 07/18/2023]
Abstract
Acute kidney injury (AKI) is a common complication of cirrhosis, burdened by high morbidity and mortality rates and progression to chronic kidney disease. Hepatorenal syndrome (HRS) is a peculiar type of functional AKI observed in cirrhotic patients with ascites. HRS diagnosis is still clinical, once pre-renal azotemia and intrinsic kidney damage have been excluded by applying well-established and internationally adopted criteria. HRS is considered reversible because of the absence of intrinsic renal damage. However, HRS reversibility has been questioned, due to the lack of response to treatment with vasoconstrictors plus albumin in a relevant percentage of patients and to the persistence of renal dysfunction in HRS patients who underwent liver transplantation (LT). Indeed, LT is the only ultimate treatment, as it solves both liver failure and portal hypertension. Thus, the presence of renal damage in HRS can be hypothesized. In this scenario, neutrophil gelatinase-associated lipocalin (NGAL), one of the most promising biomarkers, may help in characterizing the type of renal injury, distinguishing between HRS and acute tubular necrosis. This review gathers the available evidence in favor and against the presence of structural lesions in HRS in terms of either renal histology and urinary biomarkers with a particular focus on NGAL. The ability to properly characterize which component of renal dysfunction prevails - functional rather than structural - entails a relevant clinical impact for the treatment of these patients, both in terms of medical therapy and liver vs. combined liver-kidney transplantation.
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Affiliation(s)
- Alberto Calleri
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Italy.
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Maurel P, Prémaud A, Carrier P, Essig M, Barbier L, Rousseau A, Silvain C, Causse X, Debette-Gratien M, Jacques J, Marquet P, Salamé E, Loustaud-Ratti V. Evaluation of Longitudinal Exposure to Tacrolimus as a Risk Factor of Chronic Kidney Disease Occurrence Within the First-year Post-Liver Transplantation. Transplantation 2021; 105:1585-1594. [PMID: 32639405 DOI: 10.1097/tp.0000000000003384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Renal failure is predictive of mortality in the early postliver-transplantation period and calcineurin inhibitors toxicity is a main challenge. Our aim is to assess the impact of longitudinal tacrolimus exposure (TLE) and other variables on chronic kidney disease (CKD)-free 1-year-survival. METHODS Retrospective data of consecutive patients transplanted between 2011 and 2016 and treated with tacrolimus were collected. TLE and all relevant pre- and post-liver transplantation (LT) predictive factors of CKD were tested and included in a time-to-event model. CKD was defined by repeated estimated glomerular filtration rate (eGFR) values below 60 mL/min/1.73m2 at least for the last 3 months before M12 post-LT. RESULTS Data from 180 patients were analyzed. CKD-free survival was 74.5% and was not associated with TLE. Pre-LT acute kidney injury (AKI) and eGFR at 1-month post-LT (eGFRM1) <60 mL/min/1.73m2 were significant predictors of CKD. By distinguishing 2 situations within AKI (ie, with or without hepatorenal syndrome [HRS]), only HRS-AKI remained associated to CKD. HRS-AKI and eGFRM1 <60 mL/min/1.73m2 increased the risk of CKD (hazard ratio, 2.5; 95% confidence interval, 1.2-4.9; hazard ratio, 4.8; 95% confidence interval, 2.6-8.8, respectively). CONCLUSIONS In our study, TLE, unlike HRS-AKI and eGFRM1, was not predictive of CKD-free survival at 1-year post-LT. Our results once again question the reversibility of HRS-AKI.
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Affiliation(s)
- Pauline Maurel
- Hepatology and Gastroenterology Unit, University Hospital of Limoges, Limoges, France
| | - Aurélie Prémaud
- INSERM U1248, University of Limoges, F-87000, Limoges, France
- FHU SUPORT: University Hospital Federation SUrvival oPtimization in ORgan Transplantation, Limoges, F-87000, Tours, F-30000, Poitiers F-86000, Orléans F-45000, France
| | - Paul Carrier
- Hepatology and Gastroenterology Unit, University Hospital of Limoges, Limoges, France
- INSERM U1248, University of Limoges, F-87000, Limoges, France
- FHU SUPORT: University Hospital Federation SUrvival oPtimization in ORgan Transplantation, Limoges, F-87000, Tours, F-30000, Poitiers F-86000, Orléans F-45000, France
| | - Marie Essig
- INSERM U1248, University of Limoges, F-87000, Limoges, France
- FHU SUPORT: University Hospital Federation SUrvival oPtimization in ORgan Transplantation, Limoges, F-87000, Tours, F-30000, Poitiers F-86000, Orléans F-45000, France
| | - Louise Barbier
- FHU SUPORT: University Hospital Federation SUrvival oPtimization in ORgan Transplantation, Limoges, F-87000, Tours, F-30000, Poitiers F-86000, Orléans F-45000, France
- Department of Digestive Surgery and Liver Transplantation, Trousseau University Hospital, Chambray-lès-Tours, France
| | - Annick Rousseau
- INSERM U1248, University of Limoges, F-87000, Limoges, France
- FHU SUPORT: University Hospital Federation SUrvival oPtimization in ORgan Transplantation, Limoges, F-87000, Tours, F-30000, Poitiers F-86000, Orléans F-45000, France
| | - Christine Silvain
- FHU SUPORT: University Hospital Federation SUrvival oPtimization in ORgan Transplantation, Limoges, F-87000, Tours, F-30000, Poitiers F-86000, Orléans F-45000, France
- Hepatology and Gastroenterology Unit, University Hospital of Poitiers, Poitiers, France
| | - Xavier Causse
- FHU SUPORT: University Hospital Federation SUrvival oPtimization in ORgan Transplantation, Limoges, F-87000, Tours, F-30000, Poitiers F-86000, Orléans F-45000, France
- Hepatology and Gastroenterology Unit, Regional Hospital Center of Orléans, Orléans La Source, France
| | - Marilyne Debette-Gratien
- Hepatology and Gastroenterology Unit, University Hospital of Limoges, Limoges, France
- INSERM U1248, University of Limoges, F-87000, Limoges, France
- FHU SUPORT: University Hospital Federation SUrvival oPtimization in ORgan Transplantation, Limoges, F-87000, Tours, F-30000, Poitiers F-86000, Orléans F-45000, France
| | - Jérémie Jacques
- Hepatology and Gastroenterology Unit, University Hospital of Limoges, Limoges, France
| | - Pierre Marquet
- INSERM U1248, University of Limoges, F-87000, Limoges, France
- FHU SUPORT: University Hospital Federation SUrvival oPtimization in ORgan Transplantation, Limoges, F-87000, Tours, F-30000, Poitiers F-86000, Orléans F-45000, France
| | - Ephrem Salamé
- FHU SUPORT: University Hospital Federation SUrvival oPtimization in ORgan Transplantation, Limoges, F-87000, Tours, F-30000, Poitiers F-86000, Orléans F-45000, France
- Department of Digestive Surgery and Liver Transplantation, Trousseau University Hospital, Chambray-lès-Tours, France
| | - Véronique Loustaud-Ratti
- Hepatology and Gastroenterology Unit, University Hospital of Limoges, Limoges, France
- INSERM U1248, University of Limoges, F-87000, Limoges, France
- FHU SUPORT: University Hospital Federation SUrvival oPtimization in ORgan Transplantation, Limoges, F-87000, Tours, F-30000, Poitiers F-86000, Orléans F-45000, France
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Mauro E, Garcia-Olveira L, Gadano A. End-stage liver disease: Management of hepatorenal syndrome. Liver Int 2021; 41 Suppl 1:119-127. [PMID: 34155791 DOI: 10.1111/liv.14866] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 02/28/2021] [Indexed: 12/14/2022]
Abstract
Hepatorenal syndrome (HRS) is a serious complication of cirrhosis with high morbidity and mortality rates. Recently, the definition of HRS type 1 has been updated and is now called HRS-AKI. This new definition reduces the risk of delaying HRS treatment and eliminates the need to establish a minimum creatinine cut-off for the diagnosis of HRS-AKI. From a pathophysiological point of view, newly identified mechanisms involved in the development of HRS are related to the inflammatory response, conditioning the development of extrahepatic organ dysfunction in patients with cirrhosis. One of the main challenges for the diagnosis of HRS is the validation of new biomarkers to obtain an early and differential diagnosis of kidney injury (eg HRS vs. ATN). Treatment of HRS is based on the use of vasoconstrictive agents in combination with albumin and terlipressin is the most widely used vasoconstrictor drug, with a high response rate. The effects of a continuous infusion of terlipressin at a dose of 2-12 mg/day was similar to bolus administration, but with lower rates of adverse events. Finally, MELD/MELD-Na which includes creatinine as one of its main determinants gives AKI-HRS patients priority on the waiting list (WL) for liver transplant (LT). However, the MELD and MELD-Na scores are reduced in responding patients, resulting a longer waiting time in these patients than in non-responders. Thus, the initial MELD/MELD-Na score (pre-treatment value) should be used to prioritize patients on the WL for LT in these cases.
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Affiliation(s)
- Ezequiel Mauro
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Adrián Gadano
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Juanola A, Solé C, Toapanta D, Ginès P, Solà E. Monitoring Renal Function and Therapy of Hepatorenal Syndrome Patients with Cirrhosis. Clin Liver Dis 2021; 25:441-460. [PMID: 33838860 DOI: 10.1016/j.cld.2021.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Acute kidney injury (AKI) is a frequent complication in patients with cirrhosis. Patients with cirrhosis can develop AKI due to different causes. Hepatorenal syndrome (HRS) is a unique cause of AKI occurring in patients with advanced cirrhosis and is associated with high short-term mortality. The differential diagnosis between different causes of AKI may be challenging. In this regard, new urine biomarkers may be helpful. Liver transplantation is the definitive treatment of patients with HRS-AKI. Vasoconstrictors and albumin represent the first-line pharmacologic treatment of HRS-AKI. This review summarizes current knowledge for the diagnosis and management of HRS in cirrhosis.
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Affiliation(s)
- Adrià Juanola
- Liver Unit, Hospital Clínic de Barcelona, 08036 Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain
| | - Cristina Solé
- Liver Unit, Hospital Clínic de Barcelona, 08036 Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - David Toapanta
- Liver Unit, Hospital Clínic de Barcelona, 08036 Barcelona, Catalonia, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clínic de Barcelona, 08036 Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain.
| | - Elsa Solà
- Liver Unit, Hospital Clínic de Barcelona, 08036 Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain
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