Beruflich Dokumente
Kultur Dokumente
By Mohammed Dabbour
Lecturer of Anesthesia
Ain shams University
Outline
Introduction
Definition
Epidemiology
Pathophysiology
Precipitating factors
Diagnosis
Management (Prevention and treatment)
Conclusion
Introduction
Renal dysfunction is a common and serious
problem in patients with advanced liver disease.
In particular, alterations in renal physiology in
acute liver failure or cirrhosis with ascites can
predispose patients to a specific functional form
of renal failure known as hepatorenal syndrome
The accurate assessment of the kidney function
and injury is currently affected by the reliance on
the measured concentration of serum
creatinine,which is significantly affected by the
degree of cirrhosis, hyperbilirubinemia and the
nutritional state of the patient.
Epidemiology
Renal vasoconstriction
Worsening
Cardiac dysfunction
hyperdynamic
(septic or cirrhotic(
circulation
Renal Vasoconstrictor
↓Renal Vasodilator ↑
Biomarkers of AKI
Traditional markers:
- Serum creatinine
- Serum urea
- Urine markers
- Fractional excretion of sodium
- Urine casts on microscopy
Novel kidney biomarkers:Two serum and three
urine biomarkers
- Serum neutrophil gelatinase Lipocalin (sNGAL)
- Cystatin C
- Urinary Kidney Injury Molecule (KIM-1)
- Interleukin-18 (IL-18)
- NGAL (uNGAL)
Summary of studies evaluating the role of novel blood and
`
urine kidney injury biomarkers
Precipitating Factors
Aggressive paracentesis
Drugs
Others
Spontaneous Bacterial Peritonitis
Renal impairment is related to further
deterioration of systemic hemodynamics, mostly
by endotoxins and various cytokines induced in
SBP, causing further vasodilatation
Gastrointestinal bleeding
Acute gastrointestinal bleeding leads to acute
blood volume contraction, with decreased renal
perfusion
Aggressive paracentesis
It reduces the effective arterial blood volume
and further activates vasoconstrictor system
Drugs
- Diuretics
- Aminoglycosides
- Nonsteroidal anti-inflammatory drugs
- ACE-inhibitors
- Angiotensin II antagonists
Others:
- Surgery, acute alcoholic hepatitis and cholestasis
Definition of HRS
HRS is defined as the development of renal
failure in patients with advanced liver failure
(acute or chronic) in the absence of any
identifiable causes of renal pathology
Physical exam
Heart rate, blood pressure (including orthostatic), temperature
Signs of infection (pulmonary, abdominal, cellulitis, etc.)
Other causes of renal failure -- purpuric rash may suggest cryoglobulinemia
Investigations
Complete blood count, electrolytes, creatinine level
Urine sodium, osmolality
Urinalysis for protein, cells, and casts
Renal ultrasound
Assessment of Chronic kidney
Disease in patients with chronic
Liver disease
Timed urine creatinine clearance performs poor
significance overestimating GFR in patients with
chronic liver disease
So why use estimated GFR if it performs
so poorly ?????
Because it is the most cost-effective method of
assessing kidney function in chronic cases
Staging criteria for chronic kidney
disease
Management of HRS
Prevention & treatment
♣ Prevention:
- Prophylaxis against bacterial infection
- Volume expansion
- Strict use of diuretics
- Avoidance of nephrotoxic agents
♣ Treatment:
Initial management:
It requires exclusion of reversible or treatable
conditions
Pharmacologic therapy
Renal support
Transjugular Intrahepatic Portosystemic
Shunt
Liver transplantation
Pharmacologic therapy
● Dopamine
Has renal vasodilator effect when given in subpressor doses,
but no studies have shown convincing benifit
● Noradrenaline
was used with albumin and frusemide in management of
patients with type I HRS
● Midodrine & Octreotide
Midodrine is an oral alpha adrenergic agent and
sympathomimetic drug
Octreotide is a long acting analog of somatostatin
Combined long term administration of oral midodrine and subcutaneous
octreotide lead to improvement in renal function compared with
nonpressor doses of dopamine
● Misoprostol
It is a synthetic analogue of prostaglandin E1, acts as a
renal vasodilator
● Ornipressin
It is a nonselective agonist of V1 vasopressin receptors
that causes VC of the splanchnic vasculature, thus
increasing systemic pressure and renal perfusion
pressure
● Terlipressin
It is a synthetic analogue of vasopressin with VC
activity
. Lowers incidence of ischemic complications
. Longer half life than vasopressin
● Endothelin anatgonists
Enothelin is a potent endogenous vasoconstrictor, so
renal failure was prevented by an endothelin anatgonist,
e.g., Bosentan
● N-acetylcysteine
It is a drug with antioxidant properties
● Pentoxifyllin
It inhibits the tumor necrosis factor
Renal support
Dialysis:
The effectiveness of dialysis has not been proven
Molecular Adsorbent Recirculating System
This system is a modified form of dialysis using
albumin-containing dialysate that is recirculated
and perfused online through charcoal and anion
exchanger columns.
It enables the removal of water and albumin
bound substances
Transjugular
Intrahepatic
Portosystemic Shunt
Liver transplantation
Endstage liver and kidney disease is a
recognized indication for combined
liver-kidney transplant
Conclusion
Chronic liver disease is associated with primary
and secondary kidney disease
Evaluation of kidney function relies on the
measurement of serum creatinine, which is
affected by the degree of liver disease
Hepatologists should use exogenous measures
of kidney functions & biomarkers like cystatin C
Kidney Injury Biomarkers need further
evaluation in the chronic liver disease population
Early diagnosis potentially increases the survival
outcomes
Numerous studies have shown the benefit of
terlipressin with fewer side effects
The combination of midodrine and octreotide
can be used in absence of terlipressin
Intravenous albumin should be considered.
Orthotopic liver transplantation is the most
effective strategy for the treatment of
hepatorenal syndrome.