Creatinine (mg/dL) MonthsWeeks Therapeutic paracentesis Cefotaxime Type-2 HRSType-1 HRS Encephalopathy Jaundice CLINICAL TYPES OF HEPATORENAL SYNDROME (HRS)

DIFFERENCES BETWEEN TYPE-1 AND TYPE-2 HRS Setting Renal failure Type-2Type-1 Consequence Survival Non-azotemic cirrhosis Moderate and steady Refractory ascites Months Type-2 HRS Severe and progressive Terminal hepatorenal failure Days OnsetSpontaneousPrecipitated

HRS. SURVIVAL Type-1 Type-2 p< Median survival Type-1 Type-2 15 days 150 days Days Probability 0

TIME-COURSE OF THE CIRCULATORY, NEUROHORMONAL AND RENAL FUNCTION ABNORMALITIES IN CIRRHOSIS TIME-COURSE OF THE CIRCULATORY, NEUROHORMONAL AND RENAL FUNCTION ABNORMALITIES IN CIRRHOSIS No Ascites Time Degree of splanchnic arterial vasodilation Ascites Hyperdinamic circulation  RAAS, SNS and sodium retention  ADH and hyponatremia HRS

Ruiz del Arbol et al., Hepatology 2002 CARDIOVASCULAR HEMODYNAMICS IN 8 PATIENTS DEVELOPING TYPE-1 HRS AFTER SBP CARDIOVASCULAR HEMODYNAMICS IN 8 PATIENTS DEVELOPING TYPE-1 HRS AFTER SBP At SBP diagnosisSBP-HRS 83±7MAP (mmHg)73±8* * p<0.02 PRA (ng/mL.h) SVR (dyn.s/cm -5 ) CO (L/min)5.7± ±220 18± ±320 28±12* 4.6±0.7*

Ruiz del Arbol et al., Hepatology 2005 * baseline measurements: 9±1 months prior HRS SVR (dyn.s/cm -5 )1099±811211±97NS CO (L/min)5.8±0.24.6±0.3<0.01 PRA (ng/mL.h)12.9± ±3.4<0.01 NE (pg/mL)735±691385±99<0.001 HR (bpm)86±584±4NS PCP (mmHg)8.7±16.5±1<0.01 RAP (mmHg)7±0.85±0.5<0.01 CARDIOVASCULAR HEMODYNAMICS IN 12 PATIENTS DEVELOPING TYPE-1 HRS* BaselineType-1 HRSp MAP (mmHg)84±2.670±2.3<0.001

Healthy subjects (H), cirrhotic patients without ascites (NA), with ascites (A) and with hepatorenal syndrome (HRS) REGIONAL CIRCULATORY CHANGES IN CIRRHOSIS * HNAAHRS * p<0.05 Brachial blood flow (mL/min) * Resistive index middle cerebral artery HNAA p<0.001 Maroto et al., Hepatology 1993Guevara et al., Hepatology 1998

CHANGES IN HEPATIC HEMODYNAMICS ASSOCIATED WITH TYPE-1 HRS CHANGES IN HEPATIC HEMODYNAMICS ASSOCIATED WITH TYPE-1 HRS Ruiz del Arbol et al., Hepatology 2005 HVPG IN PATIENTS DEVELOPING TYPE-1 HRS AFTER SBP HVPG IN PATIENTS DEVELOPING TYPE-1 HRS AFTER SBP HVPG (mmHg) p<0.05 At SBP diagnosis After SBP resolution Ruiz del Arbol et al., Hepatology 2002 HBF IN PATIENTS DEVELOPING TYPE-1 HRS HBF IN PATIENTS DEVELOPING TYPE-1 HRS Hepatic blood flow (mL/min) Type-1 HRS Baseline measurements: 9±1 months prior HRS Baseline

Fernández et al. (unpublished) INCIDENCE OF RELATIVE ADRENAL INSUFFICIENCY* IN CIRRHOTIC PATIENTS (n=20) WITH SEPTIC SHOCK Cirrhotics Child B25% Non-cirrhotic patients10-40% Cirrhotics Child C75% * Diagnostic criteria: - baseline cortisol <9  g/dL - increase in cortisol after ACTH <9  g/dL - peak cortisol <20  g/dL

TYPE-I HRS AS A PART OF A MULTIORGAN FAILURE Spontaneous bacterial peritonitis or other precipitating event Increase in arterial vasodilation Decrease in cardiac output Adrenal dysfunction A-II, NE, ADH  resistance to portal venous flow Regional arterial vasoconstriction Aggravation of portal hypertension Kidneys Liver Brain Liver failure Encephalopathy HRS

MAP (mmHg) PRA (ng/mL.h) NE (pg/mL) Creatinine (mg/dL) Baseline (n=15) 15± ±938 3±1 70±8 Day 7 (n=9) 2±3 550±410 2±1 77±9 Day 14 (n=7) 1±1 316±161 1±1 79±12 EFFECT OF VASOCONSTRICTORS (Ornipressin and Terlipressin) PLUS I.V. ALBUMIN IN TYPE-1 HRS GFR (mL/min)9±125±2.541±1.5 Guevara et al., Hepatology 1998; Uriz et al., J Hepatol 2000

SERUM CREATININE BEFORE AND AFTER TREATMENT OF TYPE-1 HRS (11 cases) WITH TERLIPRESSIN PLUS ALBUMIN Baseline 1 day1 month Serum creatinine (mg/dL) 2 1 After treatment Ortega et al., Hepatology 2002

Group 1 (n=154) Group 2 (n=137) * Multicenter French Study Liver transplantation12.3%-13% HRS recurrence20%-- Reversal of HRS61.7%2.9%58% Survival 1 month3%41.6%40% MCFS* (n=99) Survival 3 months0%30%22% TREATMENT OF HRS WITH VASOCONSTRICTORS AND ALBUMIN (Group 1) AND STANDARD MEDICAL THERAPY (Group 2). REVIEW OF 18 STUDIES

TREATMENT OF TYPE-1 HRS WITH TERLIPRESSIN PLUS I.V. ALBUMIN vs TERLIPRESSIN Complete response Survival >1 month OLT Terlipressin + albumin (n=13) Terlipressin (n=8) Ortega et al., Hepatology 2002

Guevara et al., Hepatology 1998 TIPS IMPROVES CIRCULATORY AND RENAL FUNCTION IN TYPE-1 HRS (7 patients) Renin (ng/mL/h) NE (pg/mL) Creatinine (mg/dL) GFR (mL/min) Baseline 1257± ±0.8 9±4 18±5 Day 7 853± ±1.0 11±5 6±2 Day ± ±0.4 27±7 3±1 After treatment

CIRCULATORY SUPPORT WITH I.V. ALBUMIN IN PATIENTS WITH SBP. EFFECT ON ARTERIAL BLOOD VOLUME Cefotaxime + albumin Cefotaxime * p< PRA (ng/mL.h) Days * * * Sort et al., N Engl J Med 1999

CIRCULATORY SUPPORT WITH I.V. ALBUMIN IN PATIENTS WITH SBP. EFFECT ON HRS DEVELOPMENT AND HOSPITAL MORTALITY Cefotaxime (n=63) Resolution of infection HRS Hospital mortality Cefotaxime + albumin (n=63) 20 (32%) 17 (27%) 6 (10%)* 57 (93%)59 (98%) * p<0.001 Sort et al., N Engl J Med 1999

Fernandez et al., Hepatology 2005 EFFECTS OF HYDROXYETHYL STARCH (HES) AND ALBUMIN (ALB) ON EFFECTIVE BLOOD VOLUME IN SBP MAP (mmHg) PRA (ng.mL/h) 76±9 80±15 5.7± ±7.3 Baseline 85±13 81±8 3.1± ±24.6 At resolution 0.01 NS 0.04 NS p HES ALB

Fernandez et al., Hepatology 2005 EFFECTS OF HYDROXYETHYL STARCH (HES) AND ALBUMIN (ALB) ON PERIPHERAL ARTERIAL CIRCULATION IN SBP SVR (dyn/cm 5 ) NO (nmol/mL) vWF:Ag (U/dL)* * vWF:Ag Von Willebrand-related antigen factor 668± ±239 61±30 39±13 297±44 331±35 Baseline 803± ±290 78±55 63±32 278±47 257±65 At resolution 0.03 NS 0.03 NS 0.01 p HES ALB

EFFECT OF I.V. ALBUMIN ON SYSTEMIC HEMODYNAMICS IN CIRRHOSIS Albumin infusion IMPROVEMENT OF CIRCULATORY DYSFUNCTION Increased systemic vascular resistance Decreased NO synthesis Inhibition of endothelial activation Intravascular volume expansion Increased cardiac preload Improvement in left ventricular function