Skip to main content
SpringerLink
Log in

Management of Refractory Ascites and Hepatorenal Syndrome

  • Published:
Current Gastroenterology Reports Aims and scope Submit manuscript

Abstract

One of the most common manifestations of the development of portal hypertension in the patient with cirrhosis is the appearance of ascites. Once ascites develops, the prognosis worsens and the patient becomes susceptible to complications such as bacterial peritonitis, hepatic hydrothorax, hyponatremia, and complications of diuretic therapy. As the liver disease progresses, the ascites becomes more difficult to treat and many patients develop renal failure. Most patients can be managed by diuretics which, when used correctly, will control the ascites. Spontaneous bacterial peritonitis can be treated effectively, but portends a worse prognosis. Once the ascites becomes refractory to diuretics, liver transplantation is the best option, although use of transjugular intrahepatic portosystemic shunts will control the ascites in many patients. Lastly, the development of hepatorenal syndrome indicates the patient’s liver disease is advanced, and transplantation again is the best option. However, use of vasoconstrictors may improve renal function in some patients, helping in their management while they await a liver transplant.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of immportance

  1. Planas R, Montoliu S, Balleste B, et al.: Natural history of patients hospitalized for management of cirrhotic ascites. Clin Gastroenterol Hepatol 2006;4:1385–94.

    Article  PubMed  Google Scholar 

  2. Salerno F, Camma C, Enea M, et al.: Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology 2007;133:825–34.

    Article  CAS  PubMed  Google Scholar 

  3. Gines P, Cardenas A: The management of ascites and hyponatremia in cirrhosis. Semin Liver Dis 2008;28:43–58.

    Article  CAS  PubMed  Google Scholar 

  4. Sort P, Navasa M, Arroyo V, et al.: Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999;341:403–9.

    Article  CAS  PubMed  Google Scholar 

  5. Bernard B, Grange J-D, Khac EN, et al.: Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding. A meta-analysis. Hepatology 1999;29:1655–61.

    Article  CAS  PubMed  Google Scholar 

  6. Fernandez J, Navasa M, Planas R, et al.: Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis. Gastroenterology 2007;133:818–24.

    Article  CAS  PubMed  Google Scholar 

  7. Angeli P, Wong F, Watson H, et al.: Hyponatremia in cirrhosis: results of a patient population survey. Hepatology 2006;44:1535–42.

    Article  CAS  PubMed  Google Scholar 

  8. Boyer TD: Tolvaptan and hyponatremia. Hepatology 2010;51:699–702.

    CAS  PubMed  Google Scholar 

  9. Schrier RW, Gross P, Gheorghiade M, et al.: Tolvaptan, a selective oral vasopressin V2-receptor antagonist, for hyponatremia. N Engl J Med 2006;355:2099–2112.

    Article  CAS  PubMed  Google Scholar 

  10. • Kim WR, Biggins SW, Kremers WK, et al.: Hyponatremia and mortality among patients waiting for liver transplantation. N Engl J Med 2008;359:1018–26. This work defined the influences of hyponatremia on survival in patients with advanced liver disease. Hyponatremia is an independent risk factor of death and may be added to the MELD score for determining which patients should receive an organ for liver transplantation.

    Article  CAS  PubMed  Google Scholar 

  11. Strauss RM, Boyer TD: Hepatic hydrothorax. Semin Liver Dis 1997;17:227–232.

    Article  CAS  PubMed  Google Scholar 

  12. Boyer TD, Haskel Z: AASLD Practice Guidelines: The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology 2005;41:386–400.

    Article  PubMed  Google Scholar 

  13. Arroyo V, Gines P, Guevara M, Rodes J: Renal dysfunction in cirrhosis: pathophysiology, clinical features and therapy. In Hepatology: A textbook of liver disease, Ed. 5, Zakim D and Boyer TD eds, WB Saunders, 2006, p. 417–452.

  14. Tito L, Gines P, Arroyo V, et al.: Total paracentesis associated with intravenous albumin management of patients with cirrhosis and ascites. Gastroenterology 1990;98:146–51.

    CAS  PubMed  Google Scholar 

  15. Angermayr B, Cejna M, Koenig F, et al.: Survival in patients undergoing transjugular intrahepatic portosystemic shunt: ePTFE-covered stent grafts versus bare stents. Hepatology 2003;38:1043–50.

    PubMed  Google Scholar 

  16. Nair S, Verma S, Thuluvath PJ: Pretransplant renal function predicts survival in patients undergoing orthotopic liver transplantation. Hepatology 2002;1179–85.

  17. Weismuller TJ, Prokein J, Becker T, et al.: Prediction of survival after liver transplantation by pre-transplant parameters. Scan J Gastroenterol 2008;43:736–746.

    Article  Google Scholar 

  18. Schrier RW, Arroyo V, Bernardi M, et al.: Peripheral arterial vasodilaton hypothesis: a proposal for the initation of renal sodium and water retention in cirrhosis. Hepatology 1988;8:1151–7.

    Article  CAS  PubMed  Google Scholar 

  19. • Ginès P, Schrier RW: Renal failure in cirrhosis. N Engl J Med 2009;361;13: 1279–1290. This excellent review discusses the pathogenesis of renal failure in patients with cirrhosis. Also, current treatments are reviewed and guidelines provided to the clinician on evaluation and management of the patient with cirrhosis and renal failure.

    Article  PubMed  Google Scholar 

  20. Iwakiri Y: The molecules: mechanisms of arterial vasodilatation observed in the splanchnic and systemic circulation in portal hypertension. J Clin Gastroenterol 2007;Suppl 3:S288–S294.

    Article  Google Scholar 

  21. Martin, PY, Ginès P, Schrier RW: Nitric oxide as a mediator of hemodynamic abnormalities and sodium and water retention in cirrhosis. N Engl J Med 1998; 339:533–541.

    Article  CAS  PubMed  Google Scholar 

  22. Arroyo V, Ginès P, Gerbes AL, et al.: Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. Hepatology 1996;23:164–176.

    Article  CAS  PubMed  Google Scholar 

  23. Wiest R, Das S, Cadelina G, et al.: Bacterial translocation in cirrhotic rats stimulates eNOS-derived NO production and impairs mesenteric vascular contractility. J. Clin Invest 1999;104:1223–1233.

    Article  CAS  PubMed  Google Scholar 

  24. Wiest R, Garcia-Tsao G: Bacterial translocation (BT) in cirrhosis. Hepatology 2005;41:422–433.

    Article  CAS  PubMed  Google Scholar 

  25. Albillos A, de la Hera A, González M, et al.: Increased lipopolysaccharide binding protein in cirrhotic patients with marked immune and hemodynamic derangement. Hepatology 2003;37:208–217.

    Article  CAS  PubMed  Google Scholar 

  26. Fraces R, Zapater P, Gonzalez M, et al.: Bacterial DNA in patients with cirrhosis and noninfected ascites mimics the soluble immune response established in patients with spontaneous bacterial peritonitis. Hepatology 2008;47:978–985.

    Article  Google Scholar 

  27. Bataller R, Ginès P, Guevara M, Arroyo V: Hepatorenal syndrome. Semin Liver Dis 1997;17:233–247.

    Article  CAS  PubMed  Google Scholar 

  28. Wadeo HM, Mai ML, Absan N, Gonwa TA: Hepatorenal syndrome: pathophysiology and management. Clin J Am Soc Nephrol 2006;1:1066.

    Article  Google Scholar 

  29. Salerno F, Gerbes A, Ginès P, et al.: Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis. Gut 2007;56:1310–1318.

    CAS  PubMed  Google Scholar 

  30. MacAulay J, Thompson K, Kibert BA, et al.: Serum creatinine in patients with advanced liver disease is of limited value for identification of moderate renal dysfunction; are the equations for estimating renal function better? Can J Gastroenterol 2006;20:521–526.

    PubMed  Google Scholar 

  31. Moore KP, Wong F, Ginès P, et al.: The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club. Heptatology 2003;38:258–266.

    Article  Google Scholar 

  32. Salerno F, Gerbes A, Gines P, et al.: Diagnosis, prevention, and treatment of the hepatorenal syndrome in cirrhosis: a consensus workshop of the International Ascites Club. Gut 2007;56:1310–1318.

    CAS  PubMed  Google Scholar 

  33. • Garcia-Tsao G, Parikh CR, Viola A: Acute kidney injury in cirrhosis. Hepatology 2008;48:2064–2077. The causes of renal failure in patients admitted with cirrhosis are defined. Most patients with cirrhosis and renal failure do not have hepatorenal syndrome, but instead have types of renal failure that are reversible. The clinician needs to be aware of all causes of renal failure in this patient population so that appropriate therapy can be given.

    Article  CAS  PubMed  Google Scholar 

  34. Angeli P, Merkel C: Pathogenesis and management of hepatorenal syndrome in patients with cirrhosis. J Hepatol 2008;48:Suppl 1:S93–S103.

    Article  CAS  PubMed  Google Scholar 

  35. Eknoyan G: Letter: renal disorders in hepatic failure. Br Med J 1974;2:670.

    Article  CAS  PubMed  Google Scholar 

  36. Martin P, Fabrizi F: Hepatitis C virus and kidney disease. J Hepatol 2008;49:613–624.

    Article  CAS  PubMed  Google Scholar 

  37. Gluud LL, Kjaer MS, Christensen E: Terlipressin for hepatorenal syndrome. Cochrane Database Sys Rev 2006;4:CD005162.

    Google Scholar 

  38. Martin-Llahi M, Pepin MN, Guevara M, et al.: Terlipressin and albumin vs. Albumin in patients with cirrhosis and hepatorenal syndrome: a randomized study. Gastroenterology 2008;134:1352–1359.

    Article  CAS  PubMed  Google Scholar 

  39. • Sanyal AK, Boyer T, Garcia-Tsao G, et al.: A randomized, prospective, double blind, placebo-controlled study of terlipressin for type I hepatorenal syndrome. Gastroenterology 2008, 134:1360–1368. This is the largest placebo-controlled trial of a vasopressor in the treatment of hepatorenal syndrome type 1. Terlipressin reversed renal failure in more patients as compared to those receiving placebo. The results of this and other trials establish that the hyperdynamic circulation and resulting renal underperfusion are the basis for the development of the hepatorenal syndrome.

    Article  CAS  PubMed  Google Scholar 

  40. Duvoux C, Zanditenas D, Hézode C, et al.: Effects of noradrenalin and albumin in patients with type I hepatorenal syndrome.: a pilot study. Hepatology 2002;36:374–380.

    Article  CAS  PubMed  Google Scholar 

  41. Angeli P, Volpin R, Gerunda G, et al.: Reversal of type I hepatorenal syndrome with the administration of midodrine and octreotide. Hepatology 1999:29:1690–1697.

    Article  CAS  PubMed  Google Scholar 

  42. Esrailian E, Pantangco ER, Kyulo NL, et al.: Octreotide/midodrine therapy significnatly improves renal function and 30-day survival in patients with type I hepatorenal syndrome. Dig Dis Sci 2007;52:742–748.

    Article  CAS  PubMed  Google Scholar 

  43. Pomier-Layrargues G, Paquin SC, Hassoun Z, et al.: Octreotide in hepatorenal syndrome: a randomized, double-bline, placebo-controlled, crossover study. Hepatology 2003;1:238–243.

    Article  Google Scholar 

  44. Alessandria C, Ozdogan O, Guevara M, et al.: MELD score and clinical type predict prognosis in hepatorenal syndrome: relevance to liver transplantation. Hepatology 2005;41:1282–1289.

    Article  PubMed  Google Scholar 

  45. Gonwa TA, Klintmalm GB, Levy M, et al.: Impact of pretransplant renal function on survival after liver transplantation. Transplantation. 1995;59:361–365.

    CAS  PubMed  Google Scholar 

  46. Restuccia T, Ortega R, Guevara M, et al.: Effects of treatment of hepatorenal syndrome before transplantation on posttransplantation outcome: a case-control study. J Hepatol 2004;40:140–146.

    Article  PubMed  Google Scholar 

  47. Wong LP, Blackley MP, Andreoni KA, et al.: Survival of liver transplant candidates with acute renal failure receiving renal replacement therapy. Kidney Int 2005;1:362–370.

    Article  Google Scholar 

  48. Wong F, Sniderman K, Liu P, Blendis L: The mechanism of the initial natriuresis after transjugular intrahepatic portosystemic shunt. Gastroenterology 1997; 3:899–907.

    Article  Google Scholar 

  49. Guevara M, Ginès P, Bandi JC, et al.: Transjugular intrahepatic portosystemic shunt in hepatorenal syndrome: effects on renal function and vasoactive systems. Hepatology 1998;28:416–422.

    Article  CAS  PubMed  Google Scholar 

  50. Brensing KA, Textor J, Perz J, et al.: Long-term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase II study. Gut 2000;47:288–295.

    Article  CAS  PubMed  Google Scholar 

  51. Wong F, Pantea L, Sniderman K: Midodrine, octreotide, albumin, and TIPS in selected patients with cirrhosis and type I hepatorenal syndrome. Hepatology 2004;40:55–64.

    Article  CAS  PubMed  Google Scholar 

  52. Rasaratnam B, Kaye D, Jennings G, et al.: The effect of selective intestinal decontamination on the hyperdynamic circulatory state in cirrhosis: a randomized trial. Ann Intern Med 2003;139:186–193.

    PubMed  Google Scholar 

Download references

Disclosure

No potential conflict of interest relevant to this article was reported.

Author information

Authors and Affiliations

  1. Department of Medicine, AHSC 245035, University of Arizona College of Medicine, Tucson, AZ, 85724, USA

    Amy N. Sussman & Thomas D. Boyer

Authors
  1. Amy N. Sussman
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Thomas D. Boyer
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Thomas D. Boyer.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Sussman, A.N., Boyer, T.D. Management of Refractory Ascites and Hepatorenal Syndrome. Curr Gastroenterol Rep 13, 17–25 (2011). https://doi.org/10.1007/s11894-010-0156-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11894-010-0156-6

Keywords

Search

Navigation