Consensus report
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consensus report Austrian consensus on the definition and treatment of portal hypertension and its complications (Billroth II) 11 1 3
7. Due to muscular atrophy and tubular creatinine secre- tion in cirrhosis, serum creatinine and creatinine clear- ance significantly overestimate renal function in HRS.
HRS type 1 occurs in patients with severe liver dysfunc- tion and is associated with a high short term mortality rate. Patients with HRS 1 should receive intensive care treatment and be immediately listed for liver transplan- tation if they are appropriate candidates. The ideal treat- ment for HRS should aim to improve renal function, prolong survival, and increase the likelihood of receiv- ing a liver transplant in suitable candidates. In order to prevent further impairment of renal function (I), therapy should be initiated as soon as the diagnosis is made. − The first therapeutic goal is targeted at the precipitating event and includes adequate hydration to ensure eu- volemia, discontinuation of diuretics and nephrotoxic medication, and withholding vasodilative agents (I). − Bacterial infection should be diagnosed early and treated aggressively with antibiotics (I). − Gastrointestinal bleeding should be managed appro- priately (I).
The most extensively investigated and thus widely used vasoconstrictors are vasopressin analogues, in particular terlipressin [ 60 – 62 ]. Terlipressin is able to improve cir- culatory dysfunction via vasoconstriction of the dilated splanchnic vascular bed by increasing arterial pressure in type I HRS [ 50 ] (I). Treatment should be initiated at a dose of 1 mg/4–6 h (i.v. bolus) and may be increased to a maximum of 2 mg/4–6 h, if an appropriate thera- peutic response cannot be achieved within 3 days [ 63 ]. Response to treatment is defined as: − reversal of HRS or complete response, when serum creatinine decreases below 1.5 mg/dL; − partial response, indicated by a decrease of serum cre- atinine of > 50 %, but not below 1.5 mg/dL; − no response, when serum creatinine levels do not de- crease more than 50 % of pretreatment values. Response to therapy with vasoconstrictors can be achieved in approximately 50 % of patients within several days up to 2 weeks [ 64 –
]. There is no evidence that in case of nonresponse, the treatment with vasocontrictors beyond 2 weeks is beneficial. Recurrence of HRS after withdrawal of therapy is rare and retreatment with vasoconstrictors is generally effec- tive. In selected patients with recurrent HRS type 1, treat- ment may be extended for more than 2 weeks and used as a bridging therapy to liver transplantation [ 67 ] (II-3). Predictive factors of response are pretreatment serum creatinine levels, bilirubin levels, increase in mean arte- rial pressure through therapy, and age [ 68 , 69 ]. Although not investigated prospectively in random- ized controlled trials, continuous infusion of terlipressin may achieve response rates comparable with those of i.v. bolus administration, but possibly with less severe com- plications [ 70 ] (II-2). Terlipressin is associated with a significant risk of sys- temic ischemic complications. Noradrenaline (0.5–3 mg/h starting dose) is an equally effective and much cheaper alternative to terlipressin. It is administered as a continuous infusion to achieve a rise in arterial pressure. It is less well studied than terlipres- sin, but this regime may be even preferred over terlipres- sin for less side effects [ 71 ] (I).
Another vasoconstrictor reported in the literature but not in general use in Austria is the alpha adrenergic ago- nist midodrine. Midodrine is given orally at doses start- ing from 2.5 to 75 mg/8 h in combination with octreotide subcutaneously at doses from 100 µg to 200 µg/8 h, but even higher doses may be necessary to achieve a thera- peutic response [ 72 , 73 ] (II-2). It is generally accepted that terlipressin and norepi- nephrine are given in combination with albumin (1 g/ kg on day 1 followed by 40 g/day) in order to improve the effect of treatment on hemodynamics [ 74 ] and should preferably be administered via a central venous line (II-1). TIPS in HRS Basically, insertion of a transjugular intrahepatic por- tosystemic shunt (TIPS) should be considered in all patients with HRS. TIPS has been shown to improve renal function in type 1 and 2 HRS [ 72 ,
, 76 may be effective in reversing HRS in some patients, its use is often limited due to advanced liver disease with serum bilirubin exceeding 5 mg/dL or hepatic enceph- alopathy [ 76 ,
]. TIPS is indicated in selected patients, mostly with HRS type II and often serves as a bridge to liver transplantation (III). Role of renal replacement therapy and artificial liver support systems Currently, there are no larger randomized controlled trials showing a survival benefit for any extracorporeal treatment modality (neither renal replacement therapy nor liver support system) for patients with hepatorenal syndrome [ 78 , 79 ]. Extracorporeal treatments (both renal replace- ment therapy and additive liver support systems) can only provide a bridge to liver transplant, but evidence from randomized controlled trials is lacking as well. No ran- domized controlled trials comparing renal replacement therapy vs. extracorporeal liver support systems looking at survival benefit have been performed so far. Both treat- Yüklə 349,78 Kb. Dostları ilə paylaş:
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