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Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Aug 28, 2016; 8(24): 999-1011
Published online Aug 28, 2016. doi: 10.4254/wjh.v8.i24.999
Outcomes of liver transplantation in patients with hepatorenal syndrome
Rohan M Modi, Nishi Patel, Sherif N Metwally, Khalid Mumtaz
Rohan M Modi, Nishi Patel, Sherif N Metwally, Department of Internal Medicine, the Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
Khalid Mumtaz, Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, the Ohio State University Medical Center, Columbus, OH 43210, United States
Author contributions: Modi RM and Mumtaz K decided upon the aims of the article, wrote the manuscript, and made necessary revisions; Patel N and Metwally SN helped in writing and reviewing the manuscript.
Conflict-of-interest statement: The authors do not have any disclosures to report.
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: Khalid Mumtaz, MD, MSc, Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, the Ohio State University Medical Center, 410 West 10th Ave, Columbus, OH 43210, United States. drkmumtaz@yahoo.com
Telephone: +1-614-6858657 Fax: +1-614-2938518
Received: April 28, 2016
Peer-review started: April 28, 2016
First decision: June 16, 2016
Revised: June 20, 2016
Accepted: July 14, 2016
Article in press: July 18, 2016
Published online: August 28, 2016
Processing time: 119 Days and 4 Hours
Abstract

Hepatorenal syndrome (HRS) plays an important role in patients with liver cirrhosis on the wait list for liver transplantation (LT). The 1 and 5-year probability of developing HRS in cirrhotic with ascites is 20% and 40%, respectively. In this article, we reviewed current concepts in HRS pathophysiology, guidelines for HRS diagnosis, effective treatment options presently available, and controversies surrounding liver alone vs simultaneous liver kidney transplant (SLKT) in transplant candidates. Many treatment options including albumin, vasoconstrictors, renal replacement therapy, and eventual LT have remained a mainstay in the treatment of HRS. Unfortunately, even after aggressive measures such as terlipressin use, the rate of recovery is less than 50% of patients. Moreover, current SLKT guidelines include: (1) estimation of glomerular filtration rate of 30 mL/min or less for 4-8 wk; (2) proteinuria > 2 g/d; or (3) biopsy proven interstitial fibrosis or glomerulosclerosis. Even with these updated criteria there is a lack of consistency regarding long-term benefits for SLKT vs LT alone. Finally, in regards to kidney dysfunction in the post-transplant setting, an estimation of glomerular filtration rate < 60 mL/min per 1.73 m2 may be associated with an increased risk of patients having long-term end stage renal disease. HRS is common in patients with cirrhosis and those on liver transplant waitlist. Prompt identification and therapy initiation in transplant candidates with HRS may improve post-transplantation outcomes. Future studies identifying optimal vasoconstrictor regimens, alternative therapies, and factors predictive of response to therapy are needed. The appropriate use of SLKT in patients with HRS remains controversial and requires further evidence by the transplant community.

Keywords: Liver transplantation; Simultaneous liver kidney transplantation; Vasopressors; Dialysis; Post-transplant outcomes; Hepatorenal syndrome

Core tip: We aim to review the literature on hepatorenal syndrome (HRS) in the setting of liver transplantation (LT) and address critical issues that are barriers to improved outcomes. Many consistencies have remained as treatment options including albumin, vasoconstrictors, renal replacement therapy, and eventual LT. Moreover, the utility of simultaneous liver kidney transplantation in HRS patients still requires further evidence by the transplant community.