Incidence, Predictive Factors, and Prognosis of the Hepatorenal Syndrome in Cirrhosis With Ascites

Incidence, Predictive Factors, and Prognosis of the Hepatorenal Syndrome in Cirrhosis With Ascites ANGELS GIN&, ANGELS ESCORSELL, PERE GINk, JOAN SAL6, WLADIMIRO JIMENEZ, GASTROENTEROLOGY 1993;105:229-236 LUIS INGLADA, MIQUEL NAVASA, JOAN CLARIA, ANTONI RIMOLA, VICENTE ARROYO, and JOAN RODk Liver Unit and Hormonal Laboratory, Hospital Clinic i Provincial, University of Barcelona, Catalunya, Spain Background: The aim of the study was to investigate the incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites. Methods: The study Is a follow-up investigation in 234 nonazotemlc patients with cirrhosis and ascites. Thirty-nine variables obtained at inclusion were ana- lyzed as possible predictors of hepatorenal syndrome occurrence (Kaplan-Meier method, Mantel-Cox test, and step-wise Cox regression procedure). Results: The probability of hepatorenal syndrome occurrence was 18% at 1 year and 39% at 5 years. Sixteen variables had predictive value for hepatorenal syndrome occurrence in the univarlate analysis: history of ascites, hepatomegaly, nutritional status, blood urea nitrogen level, serum creatinine concentration, serum sodium and potassium concentration, serum and urlne osmo- lality, urlnary sodium excretion, free water clearance after a water load, glomerular flltratlon rate, arterial pressure, plasma renin activity, plasma norepineph- rlne concentration, and esophageal varices. Neither eti- ology (alcoholic vs. nonalcoholic) nor the Child-Pugh score had predictive value. A multlvarlate analysis dis- closed only three independent predictors of hepatorenal syndrome occurrence: low serum sodium concentration, high plasma renin activity, and absence of hepatomegaly. Conclusions: The hepatorenal syndrome Is a relatively frequent complication in cirrhotic patients with ascites that Is associated with an ex- tremely short survival. Liver size, plasma renin activity, and serum sodlum concentration are predictors of hepatorenal syndrome occurrence In these patients. I? atients with advanced cirrhosis frequently develop the hepatorenal syndrome (HRS), a condition characterized by a marked reduction in renal blood flow and glomerular filtration rate (GFR) in the absence of significant histological abnormalities in the kidney and of other known causes of renal failure.‘J HRS is caused by an intense renal vasoconstriction and occurs in the setting of marked alterations in splanch- nit and systemic hemodynamics and neurohumoral systems, namely sinusoidal portal hypertension, pe- ripheral arteriolar vasodilation, increased cardiac in- dex and plasma volume, arterial hypotension, activa- tion of renin-angiotensin and sympathetic nervous systems, and nonosmotic hypersecretion of antidi- uretic hormone.>’ Since the pioneer study by Hecker and Sherlock in 1956,s it is known that HRS usually follows a progres- sive course; may appear in close temporal relationship with complications, such as gastrointestinal hemor: rhage or bacterial infections, that may act as precipitat- ing factors, and has a poor prognosis.‘,” However, no studies exist on the incidence of HRS in these patients. It is also unknown whether clinical or analytical data could predict which patients with ascites are at risk of developing HRS. The present study reports the results of a follow-up study in a large series of nonazotemic cirrhotic patients with ascites aimed at investigating the incidence, predictive factors, and prognosis of HRS in cirrhosis with ascites. Materials and Methods Study Population Between May 1980 and March 1990, 302 cirrhotic patients admitted to our unit for the treatment of an episode of ascites were included in prospective studies aimed at investigating pathophysiological and therapeutical aspects of ascites. Most of these studies have already been pub- lished.‘0-‘7 Criteria to recruit patients in these studies were ascites; clinical or previous histological data indicating the diagnosis of cirrhosis; and absence of gastrointestinal hemor- rhage within 1 month before admission, hepatic encephalop- athy or bacterial infection at the time of study, clinical, laboratory, or echographic data compatible with the diagnosis of hepatocellular carcinoma, and evidence of respira- tory, cardiac, or renal diseases. Of these 302 patients, 59 were excluded from the investigation because of renal failure (GFR of ~50 mL/min) at time of study and 9 patients because they were treated with liver transplantation at some time during the follow-up period. Therefore, the study included 234 patients. The median GFR in these patients at time of inclusion was 80 mL/min (range, 53-215 mL/min) Abbreviations used in this paper: HRS, hepatorenal syndrome; GFR, glomerular filtration rate; PRA, plasma renin activity. 0 1993 by the American GastroenteroCogical Association 0016~5065/93/$3.00

Incidence, Predictive Factors, and Prognosis of the Hepatorenal Syndrome in Cirrhosis With Ascites

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