Hepatorenal syndrome: the 8th International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group

Abstract

Introduction: Renal dysfunction is a common complication in patients with end-stage cirrhosis. Since the original publication of the definition and diagnostic criteria for the hepatorenal syndrome (HRS), there have been major advances in our understanding of its pathogenesis. The prognosis of patients with cirrhosis who develop HRS remains poor, with a median survival without liver transplantation of less than six months. However, a number of pharmacological and other therapeutic strategies have now become available which offer the ability to prevent or treat renal dysfunction more effectively in this setting. Accordingly, we sought to review the available evidence, make recommendations and delineate key questions for future studies.

Methods: We undertook a systematic review of the literature using Medline, PubMed and Web of Science, data provided by the Scientific Registry of Transplant Recipients and the bibliographies of key reviews. We determined a list of key questions and convened a two-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated recommendations and/or directions for future research.

Results: Of the 30 questions considered, we found inadequate evidence for the majority of questions and our recommendations were mainly based on expert opinion. There was insufficient evidence to grade three questions, but we were able to develop a consensus definition for acute kidney injury in patients with cirrhosis and provide consensus recommendations for future investigations to address key areas of uncertainty.

Conclusions: Despite a paucity of sufficiently powered prospectively randomized trials, we were able to establish an evidence-based appraisal of this field and develop a set of consensus recommendations to standardize care and direct further research for patients with cirrhosis and renal dysfunction.

Figure 1

Classification of hepatorenal disorder (HRD). Spectrum of hepatorenal disorders in patients with advanced cirrhosis. AKI = acute kidney injury; CKD = chronic kidney disease; KD = kidney disease; HRS = hepatorenal syndrome. (With permission)⁴⁸

Figure 2

Forest plot of meta-analysis on terlipressin plus albumin for patients with hepatorenal syndrome. The outcome measure is reversal of hepatorenal syndrome.

Figure 3

Forest plot of meta-analysis on terlipressin plus albumin for patients with hepatorenal syndrome. The outcome measure is survival.

Figure 4

Forest plot of meta-analysis on Molecular Adsorbent Recirculating System (MARS) for patients with hepatorenal syndrome. The outcome measure is improvement of hepatic encephalopathy.

Figure 5

Forest plot of meta-analysis on Molecular Adsorbent Recirculating System (MARS) for patients with hepatorenal syndrome. The outcome measure is survival.

Figure 6

Percent of Adult Simultaneous Liver-Kidney (SLK) Transplant Amongst all Cadaveric Liver Transplant Recipients (1999-2009).