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  1. Francesco Salerno1,
  2. Alexander Gerbes2,
  3. Pere Gines3,
  4. Florence Wong4,
  5. Vicente Arroyo5
  1. 1
    Department of Internal Medicine, Policlinico IRCCS San Donato, University of Milan, Italy
  2. 2
    Department of Internal Medicine II, Klinikum of the Ludwig-Maximilians-University/Großhadern, University of Munich, Germany
  3. 3
    Liver Unit, Hospital Clinic, University of Barcelona, Spain
  4. 4
    Department of Medicine, Division of Gastroenterology, Toronto General Hospital, University of Toronto, Canada
  5. 5
    Liver Unit, Hospital Clinic, University of Barcelona, Spain
  1. Francesco Salerno, Department of Internal Medicine, Policlinico IRCCS San Donato, University of Milan, Italy, Via Morandi, 30, 20097 San Donato (MI), Italy; francesco.salerno{at}unimi.it

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Umgelter and colleagues have reported that there is a general reluctance to treat cirrhotic patients with renal failure with volume resuscitation. Moreover, they are critical of the accuracy of diagnosing hepatorenal syndrome (HRS) using the infusion of pre-defined doses of albumin as recommended in our paper.1 Finally, they do not seem to share the opinion that HRS, once established, is no longer responsive to simple volume expansion, and therefore suggest investigating a goal-directed approach of treatment. We would like to take the opportunity to expand our discussion on the pathogenesis of HRS as well as on the therapeutic resources.

The fact that volume expansion is an essential component in the prevention and treatment of HRS has been confirmed in the past several years. For example, albumin is able to prevent HRS in patients with spontaneous bacterial peritonitis (SBP),1 and its prolonged administration is necessary to improve the efficacy of terlipressin or midodrine in reversing HRS type 1.24 This does not exclude, however, that simple volume expansion is insufficient to correct glomerular filtration rate in such patients.

From a pathogenetic standpoint, there are two types of functional renal failure in cirrhotic patients: one that is …

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