An important feature of the current study that deserves a comment is that according to our treatment protocol for type 1 HRS, patients with renal failure with associated bacterial infections were not treated with terlipressin and

albumin until the infection resolved. Patients with renal failure and active bacterial infections (without septic shock) are currently considered as having HRS according to the new diagnostic criteria reported in 2007.3 However, these patients were not included in our treatment protocol because patients were treated before these criteria were published, and we used the previous diagnostic criteria of HRS, which deliberately excluded patients with ongoing bacterial infections.15 Therefore, the results of this study

cannot be extrapolated to patients with HRS and associated bacterial infections. Moreover, to our knowledge, there are no reports published on the management of HRS in this patient population. Wnt inhibitor Therefore, it would be important to perform studies in this subset of patients before treatment with terlipressin Small molecule library in vitro and albumin can be recommended for this particular clinical situation. The current study has some limitations. First, the assessment of predictive factors of response to therapy should ideally be performed in a large patient population. Nonetheless, because type 1 HRS is not a common condition and terlipressin is not available in many countries, the recruitment of a large series of patients for such a study is difficult. In fact, this is one of the largest series of patients reported to date on the management of type 1 HRS. Second, the accuracy of the variables reported in the current study in predicting response to therapy would require prospective validation in other series of patients either from the same institution or, ideally, from other institutions. We are prospectively validating these predictive factors in patients with type 1 HRS treated with terlipressin and albumin in our institution, but it will take several years to accumulate a sufficient number of patients for analysis. As terlipressin becomes

available in more countries for the treatment of type 1 HRS, the evaluation of predictors of response in external series of patients would be easier to perform. In conclusion, the results of the current study Resveratrol indicate that baseline serum bilirubin and an increase in MAP at day 3 of treatment are predictive factors of response to therapy with terlipressin and albumin in patients with type 1 HRS. Future research on management of type 1 HRS should be focused on the analysis of mechanisms of impaired response to pharmacological therapy and on the implementation of new therapies for nonresponders. We thank Raquel Cela, R.N., and the nursing staff of the Liver Unit and Intensive Care Unit for their participation in the study and Marco Pavesi for statistical advice.