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Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis
  1. Francesco Salerno1,
  2. Alexander Gerbes2,
  3. Pere Ginès3,
  4. Florence Wong4,
  5. Vicente Arroyo3
  1. 1Department of Internal Medicine, Policlinico IRCCS San Donato, University of Milan, Via Morandi, 30, 20097 San Donato (MI), Italy
  2. 2Department of Internal Medicine II, Klinikum of the Ludwig-Maximilians-University/Großhadern, University of Munich, Germany
  3. 3Liver Unit, Hospital Clinic, University of Barcelona, Spain
  4. 4Department of Medicine, Division of Gastroenterology, Toronto General Hospital, University of Toronto, Canada
  1. Correspondence to:
    Francesco Salerno
    Department of Internal Medicine, Policlinico IRCCS San Donato, University of Milan, Via Morandi, 30, 20097 San Donato (MI), Italy; francesco.salerno{at}unimi.it

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Hepatorenal syndrome (HRS) is a serious complication of end-stage liver disease, occurring mainly in patients with advanced cirrhosis and ascites, who have marked circulatory dysfunction,1 as well as in patients with acute liver failure.2 In spite of its functional nature, HRS is associated with a poor prognosis,3,4 and the only effective treatment is liver transplantation.

During the 56th Meeting of the American Association for the Study of Liver Diseases, the International Ascites Club held a Focused Study Group (FSG) on HRS for the purpose of reporting the results of an international workshop and to reach a consensus on a new definition, criteria for diagnosis and recommendations on HRS treatment. A similar workshop was held in Chicago in 1994 in which standardised nomenclature and diagnostic criteria for refractory ascites and HRS were established.5 The introduction of innovative treatments and improvements in our understanding of the pathogenesis of HRS during the previous decade led to an increasing need to undertake a new consensus meeting. This paper reports the scientific rationale behind the new definitions and recommendations.

The international workshop included four issues debated by four panels of experts (see Acknowledgements). The issues were: (1) evidence-based HRS pathogenesis; (2) treatment of HRS using vasoconstrictors; (3) other HRS treatments using transjugular intrahepatic portosystemic stent-shunt (TIPS) and extracorporeal albumin dialysis (ECAD); and (4) new definitions and diagnostic criteria for HRS and recommendations for its treatment.

BACKGROUND

The definition and diagnostic criteria for HRS established in 19945 were based on the following three concepts:

  1. renal failure in HRS is functional and caused by marked intrarenal arteriolar vasoconstriction;

  2. HRS occurs in patients with systemic circulatory dysfunction caused by extra-renal vasodilatation;

  3. plasma volume expansion does not improve renal failure.

Four new concepts have emerged since then, these are:

(a) Extra-renal arterial vasodilatation occurs …

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