title: Hepatorenal syndrome: are we missing some prognostic factors?
abstract: BACKGROUND
  Hepatorenal syndrome (HRS) is the functional renal failure associated with advanced cirrhosis and has also been described in fulminant hepatic failure. Without liver transplantation its prognosis is dismal. Our study included patients with type 1 HRS associated with cirrhosis, who were not liver transplant candidates.
  
  
  OBJECTIVE
  To identify variables associated with improved survival.
  
  
  METHODS
  Sixty-eight patients fulfilled the revised Ascites Club Criteria for type 1 HRS. None of them was suitable for liver transplantation. All the patients were treated with combinations of: albumin, midodrine and octreotide, pressors, and hemodialysis.
  
  
  RESULTS
  Median survival was 13 days for the whole group. Survival varied with the end-stage liver disease (ESLD) etiology: autoimmune, 49 days, cardiac cirrhosis, 22 days, idiopathic, 15.5 days, viral, 15 days, hepatitis C and alcohol, 14.5 days, alcohol 8 days, and neoplasia 4 days (p = 0.048). Survival of HRS associated with alcoholic liver disease versus other etiologies was not statistically significant (p = 0.1). Increased serum creatinine (p = 0.02) and urinary sodium 6-10 mEq/l (p = 0.027) at the initiation of therapy were prognostic factors for mortality. HRS treatment modalities (p = 0.73), use of dialysis (p = 0.56), dialysis modality (p = 0.35), use of vasopressors (p = 0.26), pre-existing renal disease (p = 0.49), gender (p = 0.90), and age (p = 0.57) were not associated with survival.
  
  
  CONCLUSIONS
  We report for the first time ESLD etiology as a prognostic factor for survival. The renal function (expressed as serum creatinine) and urinary Na (<5 mEq/l) at the time of diagnosis were found to be associated with survival, suggesting that early treatment might increase survival.
authors.affiliation: Section of Gastroenterology and Hepatology, University of Nebraska Medical Center, 983040 Nebraska Medical Center, Omaha, NE 69198-3040, USA. molivera@unmc.edu
authors.forename: Marco
authors.initials: M
authors.lastname: Olivera-Martinez
authors.forename: Marco Olivera
authors.initials: MO
authors.lastname: Martinez
authors.forename: Harlan
authors.initials: H
authors.lastname: Sayles
authors.forename: Renuga
authors.initials: R
authors.lastname: Vivekanandan
authors.forename: Sharlene
authors.initials: S
authors.lastname: D' Souza
authors.forename: Marius C
authors.initials: MC
authors.lastname: Florescu
mesh_terms: D000418:Albumins / Q000627:therapeutic use; D000437:Alcoholism / Q000150:complications*; D001327:Autoimmune Diseases / Q000150:complications*; D003404:Creatinine / Q000097:blood; D058625:End Stage Liver Disease / Q000209:etiology* / Q000628:therapy; D005260:Female; D006526:Hepatitis C / Q000150:complications*; D006530:Hepatorenal Syndrome / Q000175:diagnosis* / Q000378:metabolism / Q000401:mortality*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D008879:Midodrine / Q000627:therapeutic use; D015282:Octreotide / Q000627:therapeutic use; D011379:Prognosis; D006435:Renal Dialysis; D012189:Retrospective Studies; D012964:Sodium / Q000652:urine; D015996:Survival Rate
chemical_list: D000418:Albumins; D008879:Midodrine; D012964:Sodium; D003404:Creatinine; D015282:Octreotide