End-stage liver disease: Management of hepatorenal syndrome
End-stage liver disease: Management of hepatorenal syndrome
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DOI：
10.1111/liv.14866
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发表时间：
2021-06-01
影响因子：
6.7
通讯作者：
Gadano, Adrian
中科院分区：
文献类型：
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作者：
Mauro, Ezequiel;Garcia-Olveira, Lucrecia;Gadano, Adrian
肝肾综合征（HRS）是肝硬化的严重并发症，发病率和死亡率高.最近，HRS 1型的定义已经更新，现在称为HRS-AKI。这一新定义降低了延迟HRS治疗的风险，并消除了为诊断HRS-AKI建立最低肌酐临界值的需要。从病理生理学的角度来看，新发现的参与HRS发展的机制与炎症反应有关，调节肝硬化患者肝外器官功能障碍的发展。HRS诊断的主要挑战之一是验证新的生物标志物，以获得肾损伤的早期和鉴别诊断（例如HRS与ATN）。HRS的治疗基于血管收缩剂与白蛋白的联合使用，特利加压素是最广泛使用的血管收缩药物，具有较高的缓解率。特利加压素以2-12 mg/天的剂量连续输注的效果与推注给药相似，但不良事件发生率较低。最后，MELD/MELD-Na（包括肌酐作为其主要决定因素之一）使AKI-HRS患者在肝移植（LT）的等待名单（WL）上享有优先权。然而，MELD和MELD-Na评分在应答患者中降低，导致这些患者的等待时间长于无应答者。因此，在这些情况下，应使用初始MELD/MELD-Na评分（治疗前值）优先考虑WL中的患者进行LT。
Hepatorenal syndrome (HRS) is a serious complication of cirrhosis with high morbidity and mortality rates. Recently, the definition of HRS type 1 has been updated and is now called HRS-AKI. This new definition reduces the risk of delaying HRS treatment and eliminates the need to establish a minimum creatinine cut-off for the diagnosis of HRS-AKI. From a pathophysiological point of view, newly identified mechanisms involved in the development of HRS are related to the inflammatory response, conditioning the development of extrahepatic organ dysfunction in patients with cirrhosis. One of the main challenges for the diagnosis of HRS is the validation of new biomarkers to obtain an early and differential diagnosis of kidney injury (eg HRS vs. ATN). Treatment of HRS is based on the use of vasoconstrictive agents in combination with albumin and terlipressin is the most widely used vasoconstrictor drug, with a high response rate. The effects of a continuous infusion of terlipressin at a dose of 2-12 mg/day was similar to bolus administration, but with lower rates of adverse events. Finally, MELD/MELD-Na which includes creatinine as one of its main determinants gives AKI-HRS patients priority on the waiting list (WL) for liver transplant (LT). However, the MELD and MELD-Na scores are reduced in responding patients, resulting a longer waiting time in these patients than in non-responders. Thus, the initial MELD/MELD-Na score (pre-treatment value) should be used to prioritize patients on the WL for LT in these cases.