Hepatorenal syndrome: the 8th international consensus conference of the Acute Dialysis Quality Initiative (ADQI) Group
1 Department of Medicine, University of Southern California, 1520 San Pablo Street, Suite 4300, Los Angeles, CA, 90033 USA
2 Department of Critical Care Medicine, University of Pittsburgh, Room 608, Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261 USA
3 Department of Medicine, University College London Medical School, Rowland Hill Street, London NW3 2PF UK
4 Department of Medicine, University of Toronto, 9th Floor Rm. 9N983, 200 Elizabeth Street, Toronto, ON M5G 2C4 Canada
5 Department of Medicine, University of Washington, Box 356174, 1959 NE Pacific Street, Seattle, WA 98195, USA
6 Department of Medicine, University of Alberta, 11-107 csb 8440 112 Street, Edmonton, Canada T6G 2G3, AB, Canada
7 Department of Medicine, University of Alabama, ZRB 605, 1530 3rd Ave. S, Birmingham, AL 35294-0007 USA
8 Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Alfred Centre, Commercial Rd, Prahran, Melbourne, Victoria 3181, Australia
9 Department of Surgery, University of Southern California, 1510 San Pablo Street, Suite 200, Los Angeles, CA, 90033 USA
Critical Care 2012, 16:R23 doi:10.1186/cc11188
See related letter by Parikh and Moitra, http://ccforum.com/content/16/2/421Published: 9 February 2012
Renal dysfunction is a common complication in patients with end-stage cirrhosis. Since the original publication of the definition and diagnostic criteria for the hepatorenal syndrome (HRS), there have been major advances in our understanding of its pathogenesis. The prognosis of patients with cirrhosis who develop HRS remains poor, with a median survival without liver transplantation of less than six months. However, a number of pharmacological and other therapeutic strategies have now become available which offer the ability to prevent or treat renal dysfunction more effectively in this setting. Accordingly, we sought to review the available evidence, make recommendations and delineate key questions for future studies.
We undertook a systematic review of the literature using Medline, PubMed and Web of Science, data provided by the Scientific Registry of Transplant Recipients and the bibliographies of key reviews. We determined a list of key questions and convened a two-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated recommendations and/or directions for future research.
Of the 30 questions considered, we found inadequate evidence for the majority of questions and our recommendations were mainly based on expert opinion. There was insufficient evidence to grade three questions, but we were able to develop a consensus definition for acute kidney injury in patients with cirrhosis and provide consensus recommendations for future investigations to address key areas of uncertainty.
Despite a paucity of sufficiently powered prospectively randomized trials, we were able to establish an evidence-based appraisal of this field and develop a set of consensus recommendations to standardize care and direct further research for patients with cirrhosis and renal dysfunction.