From the Guidelines
Dialysis does not inherently worsen Hepatorenal Syndrome (HRS), but rather serves as a bridge therapy to manage complications such as volume overload, electrolyte derangements, or uremia in patients awaiting liver transplantation or potential candidates for it. The primary goal of dialysis in HRS is to provide temporary support for patients with severe kidney dysfunction, as the underlying cause of HRS is related to liver disease rather than kidney disease itself 1. According to the AGA clinical practice update on the evaluation and management of acute kidney injury in patients with cirrhosis, dialysis is indicated in patients with HRS-AKI unresponsive to pharmacologic therapy as a bridge to liver transplantation (LT) for current candidates or those who may become candidates 1.
Key points to consider in the management of HRS include:
- The preferred method of renal replacement therapy (RRT) is continuous RRT, which results in lower fluid shifts and reduced hemodynamic instability compared to intermittent RRT 1.
- Two-thirds of patients with HRS-AKI undergoing RRT pre-transplantation recover renal function when they receive a liver transplant, with the cutoff duration of RRT for predicting renal function recovery being approximately 14 days 1.
- For every additional day of dialysis pre-transplantation, there is a 3.6%–6% increased risk for renal non-recovery post-transplantation, highlighting the importance of timely liver transplantation 1.
It's crucial to note that while dialysis can manage certain complications of HRS, the definitive treatment for HRS remains liver transplantation, as it addresses the underlying liver dysfunction causing the kidney impairment. Patients with HRS who require dialysis have a poorer prognosis, but this is reflective of the severity of their underlying liver and kidney disease rather than a direct harmful effect of dialysis itself.
From the Research
Hepatorenal Syndrome and Dialysis
- Hepatorenal syndrome (HRS) is a type of renal failure that occurs in patients with advanced cirrhosis, characterized by splanchnic arterial vasodilation, renal vasoconstriction, reduced effective arterial volume, and potentially reduced cardiac output 2.
- The primary role of treatment options for HRS is to provide a bridge to liver transplantation, with the goal of reversing renal failure and providing symptomatic relief 2.
- Dialysis is not a primary treatment for HRS, and its role in managing the condition is still being evaluated 2, 3.
Effect of Dialysis on HRS
- There is limited evidence on the effect of dialysis on HRS, and most studies focus on the treatment of HRS using vasoconstrictor drugs, albumin, and transjugular intrahepatic portosystemic shunt (TIPS) 4, 5, 6.
- Renal replacement therapy, including dialysis, may be necessary in patients with HRS who develop acute kidney injury or chronic kidney disease, but its impact on the prognosis of HRS is unclear 3.
- The use of dialysis in patients with HRS is often supportive, aiming to maintain euvolemia and hemodynamics, and optimize renal perfusion and preserve renal function 3.
Treatment Options for HRS
- Vasoconstrictor drugs, such as terlipressin, and albumin are commonly used to treat HRS, with the goal of improving renal function and reducing mortality 2, 5.
- TIPS is a surgical option for patients with HRS, which can improve renal function and reduce portal pressure 5, 6.
- Liver transplantation is the definitive treatment for HRS, and can correct the underlying pathophysiological abnormalities associated with the condition 2, 5.