title: Targeting an early and substantial increase in mean arterial pressure is critical in the management of type 1 hepatorenal syndrome: a combined retrospective and pilot study.
abstract: BACKGROUND
  Appreciation of the central role for arterial vasodilatation in the pathogenesis of hepatorenal syndrome (HRS) has led to routine use of vasoconstrictors in combination with albumin as a medical therapy for HRS. Various vasoconstrictors have been explored but the optimal approach for such therapies has not yet been established.
  
  
  OBJECTIVE
  The purpose of this study was to examine the role of targeting an early and substantial increase in mean arterial pressure (MAP) in the management of type 1 HRS, a condition associated with very poor prognosis.
  
  
  METHODS
  A total of 59 patients with type 1 HRS who received a combination therapy of vasoconstrictors and albumin were enrolled into a retrospective cohort study. Subjects having a substantial increase of more than 10 mmHg in MAP by day 3 after initiation of therapy were categorized as MAP responders and the rest as MAP non-responders. In addition, five patients were enrolled into a prospective pilot study in which a titration protocol of vasoconstrictors was followed to achieve early goal-directed therapy (EGDT).
  
  
  RESULTS
  MAP responders achieved significantly higher incidence of treatment success or total response, less requirement of dialysis and more incidence of liver transplantation. More importantly, this response is associated with better short-term and long-term overall survival as well as transplant-free survival. The effectiveness of such an approach was further confirmed in the pilot study which followed an EGDT protocol.
  
  
  CONCLUSIONS
  Using an early and substantial increase in MAP as a therapeutic target is associated with favorable clinical outcomes in the management of type 1 HRS.
authors.affiliation: Division of Nephrology, Department of Medicine, St. Louis University, St. Louis, MO, 63110, USA.
authors.forename: Geetha
authors.initials: G
authors.lastname: Maddukuri
authors.forename: Cindy X
authors.initials: CX
authors.lastname: Cai
authors.forename: Satish
authors.initials: S
authors.lastname: Munigala
authors.forename: Farnaz
authors.initials: F
authors.lastname: Mohammadi
authors.forename: Zhiwei
authors.initials: Z
authors.lastname: Zhang
mesh_terms: D000418:Albumins / Q000627:therapeutic use; D062186:Arterial Pressure / Q000187:drug effects*; D018450:Disease Progression; D018572:Disease-Free Survival; D004359:Drug Therapy, Combination; D061345:Early Medical Intervention; D005260:Female; D006530:Hepatorenal Syndrome / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D006801:Humans; D053208:Kaplan-Meier Estimate; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D008879:Midodrine / Q000627:therapeutic use; D015282:Octreotide / Q000627:therapeutic use; D010865:Pilot Projects; D011446:Prospective Studies; D006435:Renal Dialysis; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000627:therapeutic use*; D014664:Vasodilation / Q000187:drug effects*
chemical_list: D000418:Albumins; D014662:Vasoconstrictor Agents; D008879:Midodrine; D015282:Octreotide