title: A Treat-to-Target Concept to Guide the Medical Management of Hepatorenal Syndrome.
abstract: BACKGROUND
  The principle of treating-to-target has been successfully applied to many diseases with significant improvement in patient care and as a useful guidance for healthcare providers. 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 in patients with HRS. An appropriate target to guide such therapy, however, has not yet been established.
  
  
  OBJECTIVE
  The purpose of the current study was to identify a suitable target that can predict clinical outcome and guide the medical management of type 1 HRS, a condition associated with very poor prognosis.
  
  
  METHODS
  A total of 85 patients with type 1 HRS who received a combination therapy of vasoconstrictors and albumin were enrolled. A potential therapeutic target was identified by univariate and multivariate logistic regression analyses. The treat-to-target concept to guide the management of HRS was then tested via a retrospective cohort study.
  
  
  RESULTS
  A change in mean arterial pressure (MAP) during treatment was identified as a sole independent predictor for patient survival. Compared with mild or no increase in MAP, achievement in a marked increase in MAP of more than 10 mmHg in these patients was associated with better overall survival and transplant-free survival. Increased MAP to higher than 15 mmHg did not result in further improvement in clinical outcome.
  
  
  CONCLUSIONS
  A treat-to-target concept by the use of a specific goal of MAP is feasible and may potentially guide the medical management of type 1 HRS.
authors.affiliation: Division of Gastroenterology, Department of Medicine, VA Loma Linda Healthcare System and Loma Linda University, Loma Linda, CA, 92357, USA.
authors.forename: Cindy X
authors.initials: CX
authors.lastname: Cai
authors.forename: Geetha
authors.initials: G
authors.lastname: Maddukuri
authors.forename: Navin
authors.initials: N
authors.lastname: Jaipaul
authors.forename: Zhiwei
authors.initials: Z
authors.lastname: Zhang
mesh_terms: D000418:Albumins / Q000627:therapeutic use*; D062186:Arterial Pressure / Q000187:drug effects; D019091:Critical Pathways; D018572:Disease-Free Survival; D004359:Drug Therapy, Combination; D005240:Feasibility Studies; 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; D010952:Plasma Substitutes / Q000627:therapeutic use*; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000627:therapeutic use*; D014664:Vasodilation / Q000187:drug effects
chemical_list: D000418:Albumins; D010952:Plasma Substitutes; D014662:Vasoconstrictor Agents