Hepatorenal syndrome

Table 4 Invasive therapies

Author andYear	N (# Type 1,# Type 2)	Study design	Intervention	Outcomemeasures	Meanbaseline SCr	Meanfollow-up SCr	Other results	Comments
Brensing et al[50] 2000	31 (14/17); an additional 10 were too sick to receive TIPS	Phase II	TIPS	Safety and survival	(Of the 31 patients who received TIPS) 2.3 ± 1.7 mg/dL	Wk 4: 1.5 ± 1.2 mg/dL	Renal function improved within 2 wk after TIPS and subsequently stabilized.	Three-month survival rate was 81% (10% of non- shunted patients survived, but they were felt to be too sick to receive TIPS). There was 1 TIPS-related death.
Wong et al[46] 2004	14 (14/0)	Prospective	Midodrine, octreotide, albumin, and TIPS	Efficacy (serum creatinine < 135 μmol/L for at least 3 d)	Responders: 233 ± 29 μmol/L Nonresponders: 345 ± 83 μmol/L	Responders: 112 ± 8 μmol/L after medical therapy Nonresponders: 476 ± 139 μmol/L after medical therapy.	Renal function improved in 10 of 14 patients (71%) with medical therapy. Five responders received TIPS; their renal function continued to improve. Mean GFR was 96 ± 20 mL/min by 12 mo post-TIPS.	TIPS was performed in responders who were stable. Two of the five responders who did not receive TIPS underwent liver transplantation, and their SCr remained normal at the time of liver transplantation.
Alessandria et al[36] 2002	16 (0/11, and an additional 5 with “organic renal disease”)	Prospective, nonrandomized	Terlipressin for 7 d (and TIPS in stable patients)	Efficacy	2.4 ± 0.9 mg/dL	After terlipressin therapy: 1.8 ± 0.8 mg/dL After TIPS: 1.4 ± 0.3 mg/dL	Terlipressin: 8 of 11 HRS patients had improved renal function (and 7 of the 8 responders had reversal of HRS (SCr < 1.5 mg/dL) Subsequent TIPS: 8 of 9 patients (89%) who underwent TIPS had improved renal function by 1 mo.	Renal function improved significantly after TIPS in all patients who responded to terlipressin. One HRS patient who did not respond to terlipressin underwent TIPS and responded. In the non-HRS group (with “organic renal disease”, only one patient had an improved SCr (from 3.7 to 1.8 mg/dL) with terlipressin treatment.
Guevara et al[49] 1998	7 (7/0)	Prospective	TIPS	Efficacy	4.9 ± 0.8 mg/dL	1 wk after TIPS: 3.7 ± 1.0 mg/dL 1 mo after TIPS: 1.8 ± 0.4 mg/dL	Renal function improved in 6 of 7 patients.	Mean survival was 4.7 ± 2 mo.
Witzke et al[53] 2004	30 (NS)	Prospective	CVVHD (if mechanically ventilated) vs intermittent HD if not ventilated	Survival	N/A	N/A	8 of 15 patients who received HD survived. None of the ventilated patients (received CVVHD) survived.	Note that the sickest patients (on a ventilator) all received CVVHD.
Keller et al[54] 1995	26 (NS); an additional 81 patients had liver disease and renal failure, but were not diagnosed with HRS	Retrospective	HD	Risk factor evaluation and outcomes	N/A	N/A	7 of 16 patients with HRS who received HD survived, while only 1 out of 16 patients with HRS who did not receive HD survived.
Mitzner et al[55] 2000	13 (Type 1)	Prospective, randomized, controlled	MARS and HDF and standard medical therapy vs HDF and medical therapy	Survival	MARS + HDF: 3.8 ± 1.5 mg/dL HDF alone: 4.4 ± 1.3 mg/dL	MARS + HDF: 2.3 ± 1.5 mg/dL HDF alone: 3.8 ± 0.5 mg/dL	At one week: 62.5% mortality in the treatment group, and 100% mortality in the group who did not receive MARS.	None of these patients underwent liver transplantation or received TIPS or vasopressin analogues during the observation period.
Jalan et al[66] 2003	8 (5/2, and one patient without HRS)	Prospective, nonrandomized	MARS	Safety and efficacy	162 (51–312) μmol/L	108 (34–231) μmol/L	50% survival at 3 mo follow-up	All of the patients had alcoholic hepatitis and were encephalopathic. Renal function improved in all patients. Of the 5 patients with type 1 HRS, 3 remained anuric, but there was normalization of SCr in the other 2 patients. SCr was normalized in both patients with type 2 HRS by the end of treatment.
Mitzner et al[55] 2001	8 (NS)	Uncontrolled	MARS	Multiple organ function changes	380 ± 182 μmol/L	163 ± 119 μmol/L	Improvement in multiple organ functions

SCr: Serum creatinine; CrCl: Creatinine clearance; TIPS: Transjugular intrahepatic portosystemic shunt; NS: Not Specified; CVVHD: Continuous veno-venous hemodialysis; HD: Hemodialysis; MARS: Molecular adsorbents recirculating system; HDF: Hemodiafiltration. Cr conversion from μmol/L to mg/dL: divide by 88.4.