Patients with Hepatorenal Syndrome Should Be Dialyzed? PRO

Abstract

Decompensated cirrhosis is an ominous medical condition that often places health care providers at a quandary of managing very complex clinical scenarios. The complexity of those scenarios further escalates when AKI superimposes over decompensated cirrhosis, signifying the collision of two life-threatening disorders. Arguably, the difficulty of managing the coexistence of decompensated cirrhosis and AKI reaches its peak when the medical decision-making conundrum around the provision of dialysis is faced, particularly when the etiology of AKI is presumed to be hepatorenal syndrome type 1 (HRS-1). HRS-1 is a unique form of AKI in patients with cirrhosis and portal hypertension mainly characterized by a profound reduction in kidney perfusion (1,2). The cornerstone of treatment of HRS-1 is vasoconstrictor therapy. However, vasoconstrictor therapy may only lead to improvement in kidney function in up to about 30%–40% of patients (3). Thus, patients with HRS-1 often rapidly deteriorate and reach a point when dialysis becomes medically necessary. Then, the traditional view has been that HRS-1 is associated with a uniquely high mortality rate (4⇓⇓–7). In the absence of liver transplantation, its in-hospital mortality rate was reported to be around 90%, not affected by dialysis, and has a median survival of 2 weeks (5,6). As a result, because of its presumed inability to extend survival, dialysis in such settings has been historically deemed futile. The assertion that the mortality rate associated with HRS-1 is greater than that of other causes of AKI in cirrhosis originated from a report on 463 patients with cirrhosis and kidney failure (4). The reported 90-day survival rate of 201 patients diagnosed with HRS-1 was 23%, compared with 71% for those with a parenchymal cause of AKI. HRS-1 was linked to an odds ratio of 6.9 (95% confidence interval, 2.2 to 21.6) for 3-month …

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