Hepatorenal syndrome (HRS) is a functional renal disorder complicating decompensated cirrhosis. Treatments to date, except liver transplantation, have been able to improve but not normalize renal function. The aim of this study was to determine the efficacy of transjugular intrahepatic portosystemic stent shunt (TIPS) as a treatment for type 1 HRS in ascitic cirrhotic patients, following improvement in systemic hemodynamics with a combination of midodrine, octreotide, and albumin (medical treatment). Fourteen ascitic cirrhotic patients with type 1 HRS received medical therapy until their serum creatinine reached below 135 mol/L for at least 3 days, followed by a TIPS if there were no contraindications. Patients were assessed before and after medical treatment, as well as at 1 week and1, 3, 6, and 12 months post-TIPS with measurements of renal function, sodium handling, systemic hemodynamics, central blood volume, and hormonal markers. Medical therapy for 14 Ψ 3 days improved renal function (serum creatinine: 233 Ψ 29 mol/L vs. 112 Ψ 8 mol/L, P β«Ψβ¬ .001) and renal sodium excretion (5 Ψ 2 mmol/d vs. 9 Ψ 2 mmol/d, P β«Ψβ¬ .002) in 10 of the 14 patients. TIPS insertion in five of the responders further improved renal function and sodium excretion, so that by 12 months post-TIPS, glomerular filtration rate (96 Ψ 20 mL/min, P < .01 vs. pre-TIPS) and urinary sodium excretion (119 Ψ 15 mmol/d, P < .01 vs. pre-TIPS) were normal, associated with normalization of plasma renin and aldosterone levels and elimination of ascites. In conclusion, TIPS is an effective treatment for type 1 HRS in suitable patients with cirrhosis and ascites, following the improvement of renal function with combination therapy of midodrine, octreotide, and albumin. (HEPATOLOGY 2004;40: 55-64.)
H epatorenal syndrome (HRS) is a syndrome of functional renal failure occurring in patients with advanced liver failure in the absence of clinical, laboratory, or histological evidence of other known causes of renal failure. 1 The development of HRS in patients with cirrhosis and ascites is associated with a significant worsening of their prognosis with a median survival time of 1.7 weeks. 2 However, HRS has always been considered to be potentially reversible. 3 Recent advances in the understanding of the pathophysiology and the management of cirrhotic patients with refractory ascites and HRS 3 have proved that HRS can be reversed. These include various pharmacotherapies aimed at reversing the abnormal hemodynamics observed in patients with HRS. 4 Various vasoconstrictors, such as terlipressin and norepinephrine, have been shown to improve renal function in approximately two thirds of patients with HRS. 5,6 Unfortunately, the use of vasoconstrictors has been associated with ischemic side effects in up to 5% of patients. 5,6 In another small study, the combination of midodrine, octreotide, and albumin resulted in a significant decrease in serum creatinine in three of five patients with HRS without any significant ischemic side effects, 7 while the use of octreotide alone has not proved to be useful. 8 Other treatment options include the use of a transjugular intrahepatic portosystemic stent shunt (TIPS), which led to a sustained reduction in serum creatinine and some Abbreviations: HRS, hepatorenal syndrome; TIPS, transjugular intrahepatic portosystemic stent shunt.