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HRS is a form of acute or subacute renal failure characterized by severe renal vasoconstriction, which develops in decompensated cirrhosis or ALF Nearly half of patients die within 2 weeks of this diagnosis The annual incidence of HRS ranges between 8% and 40% in cirrhosis depending on the MELD score The frequency of HRS in severe acute alcoholic hepatitis and in fulminant liver failure is about 30% and 55%, respectively
Munoz S. Medical Clinics of North America July 2008
Pathogenesis
Portal hypertension leads to arterial vasodilatation and pooling of blood in the splanchnic bed, with a decrease in systemic vascular resistance The modulation of cardiac output is relatively unable to prevent the severe reduction of effective circulating volume due to the splanchnic arterial vasodilation Activation of the renin-angiotensin-aldosterone system and the sympathetic nervous system and stimulation of antidiuretic hormone release become necessary to maintain arterial blood pressure As the liver disease worsens these circulatory changes gradually increase until systemic hemodynamic stability depends on vasoconstriction of the extrasplanchnic vascular beds
Munoz S. Medical Clinics of North America July 2008
Nitric oxide
Nitric oxide (NO) is a potent vasodilator that is elevated in the peripheral circulation of patients with cirrhosis The imbalance between NO and vasoconstrictors such as endothelin-1 in the renal microcirculation has been proposed to be responsible for the progressive deterioration in kidney function in these patients
Nitric oxide has a very short half-life; therefore, measurement of the NO metabolites, nitrite and nitrate (NOx), are commonly used to estimate NO levels in the circulation Because both metabolites are excreted predominantly by the kidney, decreased renal clearance rather than overproduction could account for the elevated level of NOx in decompensated cirrhosis
Kayali et al. Journal of Gastroenterology and Hepatology February 2009
L-Arginine (L-Arg), a nonessential amino acid, is the precursor for NO production by nitric oxide synthase The liver is the major site for arginine metabolism, where arginine generated in the urea cycle is rapidly converted to urea and ornithine by arginase-1 NOS and arginase-1 compete for available arginine and it is possible that the overproduction of NO results from an excess availability of substrate
Kayali et al. Journal of Gastroenterology and Hepatology February 2009
Patients with either compensated cirrhosis, cirrhotic patients with ascites, refractory ascites (RA) or chronic hepatorenal syndrome (HRS) type II were included in the sudy Normal healthy volunteers, organ donors and chronic renal failure (CRF) patients without liver disease were included as controls
Kayali et al. Journal of Gastroenterology and Hepatology February 2009
After adjusting for all demographics and variables, HRS was the only disease state predicting high levels of NOx in the peripheral circulation (P < 0.001) Multivariate analysis also revealed that HRS was an independent factor predicting high levels of L-Arg (P = 0.03) Chronic renal failure and stages of progressive renal dysfunction in decompensated cirrhosis were not independently associated with peripheral levels of NOx or L-Arg Peripheral levels of NOx reliably reflect NOx levels in the splanchnic circulation, suggesting that peripheral levels of NOx can be used diagnostically as a marker for disease state
Treatment
TIPS Significant suppression of the endogenous vasoconstrictor systems Decrease in creatinine levels More easily controllable ascites
Midodrine/octreotide
Combination therapy with midodrine (a selective alpha-1 adrenergic agonist) and octreotide (a somatostatin analog) may be effective and safe Midodrine is a systemic vasoconstrictor and octreotide is an inhibitor of endogenous vasodilator release, combined therapy would improve renal and systemic hemodynamics
These drugs were used in three pilot studies in a total of 79 patients A complete recovery of renal failure was observed in 49% of patients. In most patients midodrine administration started at 5-10 mg t.i.d. orally, with the goal of increasing the dose to 12.5 or 15 mg t.i.d. if a reduction of serum creatinine was not observed Octreotide administration started at 100 g subcutaneously t.i.d. with the goal of increasing the dose to 200 g subcutaneously t.i.d. if a reduction of serum creatinine was not observed
Terlipressin
Terlipressin, an agonist of the V1 vasopressin receptors, is inactive in its native form, but is transformed into the biologically active form, lysine-vasopressin through enzymatic cleavage of glycyl residues by tissue peptidases Because of this modification, terlipressin has a prolonged biological half-life compared with other vasopressin analogues