Liver Tranplantation in hepatorenal syndrome

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Liver transplantation


The treatment of choice for patients with cirrhosis and
type 1 HRS who are suitable for the procedure is liver
transplantation, because it allows both the liver disease
and the associated renal failure to be cured. The most
common contraindications for transplantation in HRS are
advanced age, active alcoholism, and infection. The main
problem in the use of liver transplantation for type 1 HRS
is that many patients die before transplantation is possible
because of the short survival expectancy and long waiting
times in most transplant centres. The issue can be solved
by assigning these patients a high priority for
transplantation from a cadaveric donor. This approach
was used with the former method of organ allocation used
by the United Network for Organ Sharing in the USA,
which classified patients with HRS in the 2a status, with a
median waiting time of about 7 days. Now this system
has been changed and livers are allocated on the basis of
the MELD (model of end-stage liver disease) score, which
is obtained by a formula including serum bilirubin, serum
creatinine, and international normalised ratio.Patients
with HRS have high MELD scores even when liver
function is preserved. This system was implemented in
the USA in early 2002, and the initial results of its use
have been reported recently.The policies for allocation
of livers from cadaveric donors are not uniform in other
countries. Whatever the system used for organ allocation,
HRS should probably be treated before transplantation is
done in an attempt to improve renal function. This step
may help reduce the (moderately) higher morbidity and
mortality after transplantation reported in patients with
HRS than in those without HRS. In fact, the outcome
of transplantation for patients with HRS treated with
vasoconstrictors (vasopressin analogues) before the
procedure does not differ from that of patients without
HRS.Combined liver and kidney transplantation for
patients with HRS does not improve the overall results
obtained with liver transplantation alone and should not
be used.

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