Therapeutic alternatives for the treatment of type 1 hepatorenal syndrome: A Delphi technique-based consensus

Table 1 Criteria for the diagnosis of hepatorenal syndrome

HRS

Presence of cirrhosis and ascites

Serum creatinine > 1.5 mg/dL (or 133 micromoles/L)

No improvement of serum creatinine (decrease equal to or less than 1.5 mg/dL) after at least 48 h of diuretic withdrawal and volume expansion with albumin (recommended dose: 1 g/kg per day up to a maximum of 100 g of albumin/day)

Absence of shock

No current or recent treatment with nephrotoxic drugs

Absence of parenchymal kidney disease as indicated by proteinuria > 500 mg/d, microhematuria (> 50 RBCs/high power field, and/or abnormal renal ultrasound scanning

HRS-1

Rapidly progressive renal failure defined by a doubling of the initial serum creatinine to a level greater than 2.5 mg/dL or 220 μmol/L in less than 2 wk

Although it may appear spontaneously, HRS-1 often develops with a precipitating event, particularly spontaneous bacterial peritonitis

HRS-1 occurs in the setting of an acute deterioration of circulatory function (arterial hypotension and activation of the endogenous vasoconstrictor systems) and is frequently associated to rapid impairment in liver function and encephalopathy

HRS-2

Characterized by a moderate renal failure (serum creatinine greater than 1.5 mg/dL) which follows a steady or slowly progressive course. It appears spontaneously in most cases

HRS-2 is frequently associated with refractory ascites. Survival of patients with HRS-2 is shorter than that of patients with ascites but without renal failure

HRS: Hepatorenal syndrome; HRS-2: Type-2 HRS; HRS-1: Type-1 HRS.

Table 2 Levels of evidence according to the study design

Level of evidence	Description
Type I	Evidence obtained at least from one well-designed, randomized, controlled1 trial or from a systematic review of randomized clinical studies
Type II	II-1 evidence obtained from non-randomized, prospective, controlled1 studies
	II-2 evidence obtained from cohort observational studies2 or case-control studies, preferably multi-centric
	II-3 evidence obtained from case series
Type III	Opinion of authorities on the subject matter based on expertise, expert committees, case reports, pathophysiological studies or basic science studies

¹A controlled study is a study where the intervention is managed by the researcher;

²An observational study is a study where the intervention is not controlled by the researcher.

Table 3 Levels of recommendation according to the available evidence

Recommendation	Description
A	The consensus strongly recommends the mentioned intervention or service. This recommendation is based on high quality evidence, with a benefit that significantly exceeds the risks
B	The consensus recommends the regular clinical use of the mentioned intervention or service. This recommendation is based on moderate quality evidence, with a benefit that exceeds the risks
C	The consensus does not make any positive or negative recommendation regarding the mentioned intervention or service. A categorical recommendation is not provided, because the evidence (of at least moderate quality) does not show a satisfactory risk/benefit relationship. The decision has to be made on a case-by-case basis
D	The consensus makes a negative recommendation against the mentioned intervention or service. The recommendation is based on at least moderate quality evidence, not showing any benefit or where the risk or damage exceeds the benefits of the intervention
I	The consensus concludes that the evidence is insufficient, due to low-quality studies, heterogeneous results or because the risk/benefit balance cannot be determined