Hepatorenal syndrome: role of the transjugular intrahepatic stent shunt in real life practice.

Few and small studies on Hepatorenal syndrome (HRS) indicate the same clear benefit after trans jugular intrahepatic portosystemic stent shunt (TIPS) [1].. In particular the are no data about patients listed for liver transplantation (LT), or affected by acute alcoholic hepatitis. HRS is a common complication of end stage liver disease (ESLD) with a high three-month mortality rate (about 90%). HRS type I (HRS-I) is an acute decline in renal function with creatinine levels above 2.5 mg / dL in less than two weeks. The average survival time is two to four weeks. HRS-II is characterized by a slow and progressive deterioration of renal function, and it underlies refractory ascites. HRS is a frequent complication of alcoholic liver disease (ALD) and can be the onset of severe acute alcoholic hepatitis (AAH) [1,2]. LT is an effective therapy. When waiting for LT, TIPS may be considered an excellent “bridge” procedure. It is known, in fact, that TIPS results in decreased levels of plasmatic aldosterone, renin and noradrenaline within four to six months after placement. This corresponds to a reduction in portal hypertension [2,3]. However, TIPS can be complicated by encephalopathy and liver failure [4]. For some authors [5,6,7,8,9] the use of TIPS shall not be recommended in HRS-1 patients. Of course this consideration in relation to the serious clinical condition of these patients is shareable, although in our experience for patients already on a list for liver transplantation or in a particularly severe clinical condition, TIPS, in view of the high mortality rate in the short term, can be a useful ‘bridge’ therapy. We have considered three studies concerning cases that were followed prospectively during the period 19982006 and re-evaluated retrospectively. In the first retrospective study [10], in 18 patients waiting for LT with HRS-II and RA, and were notresponding to medical therapy, TIPS placement led to a significant improvement in the clinical-laboratory parameters. After 12 weeks we witnessed a total resolution of the ascites in 44.5% of cases and a partial remission (compensated ascites) in 55.5%. In addition, the laboratory parameters under consideration (serum creatinine, creatinineclearance, sodium excretion and urine volume) improved significantly (Table I).