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©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
Therapeutic alternatives for the treatment of type 1 hepatorenal syndrome: A Delphi technique-based consensus
Juan P Arab, Juan C Claro, Juan P Arancibia, Jorge Contreras, Fernando Gómez, Cristian Muñoz, Leyla Nazal, Eric Roessler, Rodrigo Wolff, Marco Arrese, Carlos Benítez
Juan P Arab, Rodrigo Wolff, Marco Arrese, Carlos Benítez, Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago 833-0024, Chile
Juan C Claro, Departamento de Medicina Interna and Programa de Salud Basada en la Evidencia Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago 833-0024, Chile
Juan P Arancibia, Sección de Gastroenterología, Departamento de Medicina, Hospital Clínico Universidad de Chile and Clínica Santa María, Santiago 838-0456, Chile
Jorge Contreras, Unidad de Gastroenterología, Universidad del Desarrollo, Clínica Alemana, Santiago 765-0568, Chile
Fernando Gómez, Cristian Muñoz, Servicio de Gastroenterología, Unidad de Trasplante Hepático, Hospital del Salvador, Facultad de Medicina, Universidad de Chile and Unidad de Gastroenterología, Clínica Alemana de Santiago, Clínica Indisa, Santiago 750-0922, Chile
Leyla Nazal, Clínica Las Condes y Servicio de Gastroenterología, Hospital Fuerza Aérea de Chile, Santiago 756-0171, Chile
Eric Roessler, Departamento de Nefrología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago 833-0024, Chile
Author contributions: Arab JP and Benítez C designed the survey and coordinated the expert panel; Arab JP, Claro JC, Arancibia JP, Contreras J, Gómez F, Muñoz C, Nazal L, Roessler E, Wolff R and Benítez C participated in the panel; Arab JP, Arrese M and Benítez C wrote the manuscript; all of the authors reviewed and approved the final draft.
Supported by The Sociedad Chilena de Gastroenterologí a (SCHGE) and the Asociación Chilena de Hepatología (ACHHEP).
Conflict-of-interest statement: There are no conflicts of interest arising from this work.
Data sharing statement: No further data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Carlos Benítez, MD, Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Marcoleta #367, Santiago 833-0024, Chile. benitezc@gmail.com
Telephone: +56-2-23543820 Fax: +56-2-26397780
Received: May 28, 2016
Peer-review started: May 30, 2016
First decision: July 6, 2016
Revised: July 17, 2016
Accepted: July 29, 2016
Article in press: August 1, 2016
Published online: September 8, 2016
AIM
To propose several alternatives treatment of type 1 hepatorenal syndrome (HRS-1) what is the most severe expression of circulatory dysfunction on patients with portal hypertension.
METHODS
A group of eleven gastroenterologists and nephrologists performed a structured analysis of available literature. Each expert was designated to review and answer a question. They generated draft statements for evaluation by all the experts. Additional input was obtained from medical community. In order to reach consensus, a modified three-round Delphi technique method was used. According to United States Preventive Services Task Force criteria, the quality of the evidence and level of recommendation supporting each statement was graded.
RESULTS
Nine questions were formulated. The available evidence was evaluated considering its quality, number of patients included in the studies and the consistency of its results. The generated questions were answered by the expert panel with a high level of agreement. Thus, a therapeutic algorithm was generated. The role of terlipressin and norepinephrine was confirmed as the pharmacologic treatment of choice. On the other hand the use of the combination of octreotide, midodrine and albumin without vasoconstrictors was discouraged. The role of several other options was also evaluated and the available evidence was explored and discussed. Liver transplantation is considered the definitive treatment for HRS-1. The present consensus is an important effort that intends to organize the available strategies based on the available evidence in the literature, the quality of the evidence and the benefits, adverse effects and availability of the therapeutic tools described.
CONCLUSION
Based on the available evidence the expert panel was able to discriminate the most appropriate therapeutic alternatives for the treatment of HRS-1.
Core tip: The available evidence for the treatment of type 1 hepatorenal syndrome (HRS-1) was evaluated. The role of terlipressin and norepinephrine was confirmed as the pharmacologic treatment of choice. On the other hand the use of the combination of octreotide, midodrine and albumin without vasoconstrictors was discouraged. The role of several other options was also evaluated and the available evidence was explored and discussed. Liver transplantation is considered the definitive treatment for HRS-1 and the necessary conditions to optimize the recovery of renal function was also discussed.
