Association between spontaneous portosystemic shunt and hepatorenal syndrome in liver cirrhosis / 临床肝胆病杂志

ObjectiveTo investigate the association between spontaneous portosystemic shunt （SPSS） and hepatorenal syndrome （HRS） in patients with liver cirrhosis. MethodsA retrospective analysis was performed for 93 patients with SPSS from Dezhou Hospital， Qilu Hospital of Shandong University， from January 2015 to January 2022， and the patients were followed up for 12 months with the onset of HRS as the observation endpoint. According to the presence or absence of HRS， the 93 patients with SPSS were divided into HRS group with 38 patients （40.86%） and non-HRS group with 55 patients （59.14%）， and the two groups were compared in terms of clinical data， laboratory data， complication， and shunt diameter. Based on the maximum shunt vein diameter of 1.5 cm， the 93 patients with SPSS were divided into high shunt group with 52 patients （55.91%） and low shunt group with 41 patients （44.09%）， and with the onset of HRS as the observation endpoint， the two groups were compared in terms of the incidence rate of HRS and survival time curve. The independent-samples t test was used for comparison of normally distributed continuous data with homogeneity of variance between two groups， and the chi-square test was used for comparison of categorical data between two groups. The receiver operating characteristic （ROC） curve was used to predict cut-off values， the Kaplan-Meier curve was used for comparison of survival time， and the Log-rank test was used to compare the differences in survival curves. The multivariate Cox regression analysis was used to investigate risk factors. ResultsCompared with the non-HRS group， the HRS group had significant increases in Child-Pugh score， Child-Pugh class， MELD score， serum creatinine， blood urea nitrogen， alanine aminotransferase， aspartate aminotransferase， maximum shunt vein diameter， the incidence rates of hepatic encephalopathy and spontaneous bacterial peritonitis， and the degree of ascites， as well as significant reductions in main portal vein diameter， serum sodium and albumin （all P<0.05）. Compared with the low shunt group， the high shunt group had a significant increase in the incidence rate of HRS （51.92% vs 26.83%， χ²=5.974， P=0.015） and a significant reduction in the time to the onset of HRS （Log-rank P=0.033）. A maximum shunt vein diameter of >1.5 cm （hazard ratio ［HR］=1.123， 95% confidence interval ［CI］： 1.041‍ ‍—‍ ‍1.211， P=0.003）， an increase in MELD score （HR=1.205， 95%CI： 1.076‍ ‍—‍ ‍1.437， P=0.039）， a reduction in serum albumin （HR=0.890， 95%CI： 0.814‍ ‍—‍ ‍0.974， P=0.011）， an increase in the degree of ascites （HR=2.099， 95%CI： 1.066‍ ‍—‍ ‍4.130， P=0.032）， and spontaneous bacterial peritonitis （HR=2.259， 95%CI： 1.020‍ ‍—‍ ‍5.003， P=0.045） were independent risk factors for the onset of HRS in SPSS patients. ConclusionThere is an association between SPSS and HRS， and shunt diameter >1.5 cm was an independent risk factor for HRS in SPSS patients， which should be taken seriously and require early intervention in clinical practice.

Lista de espera para transplante hepático: impacto clínico e econômico / Waiting list for liver transplantation: clinical and economic burden

ABSTRACT Background Burden of disease is an indicator that relates to health status. United States and European epidemiological data have shown that the burden of chronic liver disease has increased significantly in recent decades. There are no studies evaluating the impact of complications of chronic liver disease on the waiting list for deceased donor liver transplantation (LTx). Objective: To determine the clinical and economic burden of complications of liver disease in wait-listed patients from the perspective of a transplant center. Methods The study retrospectively analyzed medical records of 104 patients wait-listed for deceased donor LTx from October 2012 to May 2016 and whose treatment was fully provided at the study transplant center. Clinical data were obtained from electronic medical records, while economic data were collected from a hospital management software. To allocate all direct medical costs, two methods were used: full absorption costing and micro-costing. Results: The most common complication was refractory ascites (20.2%), followed by portosystemic encephalopathy (12.5%). The mean number of admissions per patient was 1.37±3.42. Variceal hemorrhage was the complication with longest median length of stay (18 days), followed by hepatorenal syndrome (13.5 days). Hepatorenal syndrome was the costliest complication (mean cost of $3,565), followed by portosystemic encephalopathy ($2,576) and variceal hemorrhage ($1,530). Conclusion: The burden of chronic liver disease includes a great cost for health systems. In addition, it is likely to be even greater as a result of the insidious course of the disease.

RESUMO Contexto O impacto da doença é um indicador relacionado ao estado de saúde. Dados epidemiológicos norte-americanos e europeus mostraram que, nas últimas décadas, o impacto da doença hepática crônica tem aumentado significativamente. Não há estudos que avaliem o impacto das descompensações da doença hepática crônica na lista de espera para transplante hepático (TxH) com doador falecido. Objetivo: Determinar o impacto clínico e econômico das descompensações da doença hepática nos pacientes em lista de espera sob a perspectiva do centro transplantador. Métodos Foram analisados, retrospectivamente, os prontuários de 104 pacientes incluídos em lista de espera para TxH com doador falecido entre outubro de 2012 e maio de 2016 e acompanhados integralmente no centro transplantador. Dados clínicos foram obtidos do prontuário eletrônico, enquanto dados econômicos foram coletados através de software de gestão hospitalar. A apropriação dos custos médicos diretos foi realizada sob duas metodologias: custeio por absorção pleno e microcusteio. Resultados: A descompensação com maior incidência foi a ascite refratária (20,2%) seguida de encefalopatia portossistêmica (12,5%). A média de internações por paciente foi de 1,37±3,42. A hemorragia digestiva alta varicosa foi a descompensação com maior tempo mediano de internação (18 dias), seguida da síndrome hepatorrenal (13,5 dias). A descompensação mais onerosa foi a síndrome hepatorrenal (custo médio de US$ 3.565), seguida encefalopatia portossistêmica (US$ 2.576) e a hemorragia digestiva alta varicosa (US$ 1.530). Conclusão O impacto da doença hepática crônica inclui um custo importante para os sistemas de saúde. Além disso, é provável que seja ainda maior em decorrência do curso insidioso da doença.

Síndrome hepatorrenal en asociación con hepatitis alcohólica y síndrome de Zieve / Hepatorenal syndrome in association with alcoholic hepatitis and Zieve's syndrome

RESUMEN La enfermedad hepática alcohólica tiene un amplio espectro de enfermedades, incluida la hepatitis alcohólica, que en sus formas graves puede conducir al síndrome hepatorrenal. La anemia es común en pacientes alcohólicos, pero una anemia hemolítica asociada con hiperlipidemia e ictericia se reconoce como síndrome de Zieve. Un varón de 42 años con consumo excesivo de alcohol fue admitido por ictericia y dolor abdominal. Durante su evolución presentó azoemia progresiva y anemia hemolítica. Se realizó el diagnóstico de síndrome hepatorrenal asociado a hepatitis alcohólica, así como un síndrome de Zieve. Fue tratado con corticoterapia y la combinación de albúmina y noradrenalina, además del retiro de alcohol, con resultados favorables.

ABSTRACT Alcoholic liver disease has a broad spectrum of diseases, including alcoholic hepatitis, which in its severe forms can lead to hepatorenal syndrome. Anemia is common in alcoholic patients, but a hemolytic anemia in association with hyperlipidemia and jaundice is recognized as Zieve's syndrome. A 42 year old man with heavy alcohol consumption was admitted for jaundice and abdominal pain. During his evolution, he presented progressive azotemia and hemolytic anemia. The diagnosis of hepatorenal syndrome associated with alcoholic hepatitis was made, as well as a Zieve's syndrome. He was treated with corticosteroid therapy and the combination of albumin and norepinephrine, in addition to alcohol withdrawal, with favorable results.

Custo efetividade do uso da terlipressina no tratamento da síndrome hepatorrenal / Cost effectiveness of using terlipressin to treat hepatorenal syndrome

ABSTRACT Background Hepatorenal syndrome (HRS) is the most severe form of acute kidney injury in patients with advanced cirrhosis, and it is associated with high mortality. It is usually diagnosed according to criteria defined by the International Ascites Club. Currently, the most frequently indicated pharmacological therapy for the treatment of HRS is a combination of splanchnic vasoconstrictors (terlipressin or norepinephrine) in combination with albumin. With the progressive increase in healthcare spending, it is important to conduct a cost-effectiveness analysis of pharmacological treatment in patients who are diagnosed with HRS. Objective: To perform a cost-effectiveness assessment for the use of terlipressin in combination with albumin to treat HRS in patients with cirrhosis. Methods: Economic evaluation of cost-effectiveness based on secondary data from studies showed the efficacy of terlipressin therapy compared with norepinephrine combined with albumin or albumin alone. The cost-effectiveness analysis was calculated using an incremental cost-effectiveness ratio (ICER), and a sensitivity analysis was developed by varying the values of therapies and probabilities. The Brazilian real was the currency used in the analysis, and the results were converted to US dollars. Results: After selection, eligibility, and evaluation of the quality of publications, the results demonstrated that administration of terlipressin or norepinephrine in combination with albumin in patients diagnosed with HRS type 1 was efficacious. The cost of treatment with terlipressin in combination with albumin was USD $1,644.06, administration of albumin alone was USD $912.02, and norepinephrine plus albumin was USD $2,310.78. Considering that the combination therapies demonstrated effectiveness, the incremental cost of terlipressin and norepinephrine in combination with albumin was USD $666.73, and an effectiveness of 0.570 was found for terlipressin in combination with albumin and 0.200 for norepinephrine in combination with albumin. The incremental effectiveness was 0.370, and the ICER was USD $1,801.97. Thus, the parameters of increasing cost per therapy and ICER indicated that the combined therapy of terlipressin plus albumin was cost effective compared to albumin alone or norepinephrine plus albumin in a public single-payer healthcare system. Conclusion: A cost-effectiveness analysis showed that terlipressin in combination with albumin when administered concomitantly to patients who were diagnosed with type 1 HRS is cost-effective compared to norepinephrine in combination with albumin administered in a controlled environment.

RESUMO Contexto: A Síndrome Hepatorrenal (SHR) é a forma mais grave de lesão renal aguda em pacientes com cirrose avançada, estando diretamente associada a alta taxa de mortalidade. Normalmente é diagnosticada seguindo critérios definidos pela International Ascites Club (IAC). Atualmente, as terapias farmacológicas mais indicadas no tratamento da SHR são a combinação de vasoconstritores esplâncnicos (terlipressina ou norepinefrina) associados à albumina. Com o aumento progressivo dos gastos em saúde, torna-se relevante realizar uma análise de custo-efetividade do tratamento farmacológico em pacientes com diagnóstico de SHR. Objetivo: Realizar avaliação de custo-efetividade do uso da terlipressina associada à albumina no tratamento da SHR em pacientes com cirrose. Métodos: Avaliação econômica de custo-efetividade, com base em dados secundários de estudos publicados com resultado da eficácia da terapia com terlipressina, em comparação com norepinefrina combinada com albumina ou apenas albumina. A análise de custo-efetividade foi calculada usando a razão de custo-efetividade incremental (RCEI) e uma análise de sensibilidade foi desenvolvida variando os valores das terapias e probabilidades. O real foi a moeda utilizada na análise. Resultados: Após a seleção, elegibilidade e avaliação da qualidade das publicações, os resultados demonstraram que a administração da associação de terlipressina ou norepinefrina com albumina em pacientes diagnosticados com SHR tipo 1 possui eficácia comprovada. Os custos do tratamento com a terapia combinada de terlipressina com albumina foram de USD $1,644.06, administração de somente albumina USD $912.02 e norepinefrina mais albumina USD $2,310.78. Considerando as terapias combinadas com efetividade terapêutica comprovada, isto é, terlipressina e norepinefrina associada a albumina, o custo incremental foi de USD $666.73 e efetividade de 0,570 para o grupo da terlipressina associada a albumina e de 0,200 para o grupo da norepinefrina associada a albumina. A efetividade incremental foi de 0,370 e o valor da RCEI foi de USD $1,801.97. Assim, os fatores de incremento do custo por terapia e razão de custo-efetividade incremental definem que a terapia combinada de terlipressina mais albumina é custo efetiva quando comparada a administração de somente albumina ou norepinefrina no cenário do sistema único de saúde. Conclusão: O estudo demonstrou por meio de uma análise de custo-efetividade que a terlipressina associada à albumina quando administrada concomitantemente a pacientes com diagnóstico de SHR tipo 1 é custo-efetiva quando comparada à albumina sozinha e com norepinefrina associada à albumina administrada em um ambiente controlado.

Síndrome hepatorrenal: revisión de la literatura

Contexto: el síndrome hepatorrenal es una disfunción renal que ocurre en pacientes con enfermedad hepática crónica como cirrosis hepática o enfermedad hepática aguda, caracterizada por la activación de mecanismos reguladores que conducen a la disminución de la tasa de filtrado glomerular. Clínicamente, el síndrome hepatorrenal se divide en dos tipos: el tipo 1 se caracteriza por una pérdida rápida y progresiva de la función renal, mientras que el tipo 2 se caracteriza por ser de progresión lenta y de mejor pronóstico. Objetivo: analizar la historia natural de la enfermedad que presentan los pacientes que desarrollan síndrome hepatorrenal. Metodología: se realizó una revisión de la literatura científica de manuscritos publicados sobre síndrome hepatorrenal, para evaluar la historia natural de esta patología. Resultados: no existen hallazgos clínicos específicos, sin embargo, sus manifestaciones clínicas reflejan la enfermedad hepática avanzada subyacente, la insuficiencia renal y las anomalías circulatorias presentes. Conclusiones: la opción terapéutica más adecuada es el trasplante hepático, pero no todos los pacientes pueden recibirlo, mientras se accede a dicho manejo una opción es el tratamiento medicamentoso con vasoconstrictores y albúmina.

Background: Hepatorenal syndrome is a renal dysfunction that occurs in patients with chronic liver disease such as liver cirrhosis or acute liver disease, characterized by the activation of regulatory mechanisms that lead to a decrease in the glomerular filtration rate. Clinically, hepatorenal syndrome is divided into two types, type 1 and type 2. Type 1 is characterized by a rapid and progressive loss of kidney function while type 2 is characterized by slow progression and a better prognosis. Purpose: To analyze the natural history of the disease presented by patients who develop hepatorenal syndrome. Methodology: A review of the scientific literature of published manuscripts on hepatorenal syndrome was carried out to evaluate the natural history of this pathology. Results: There are no specific clinical findings, however, its clinical manifestations reflect the underlying advanced liver disease, kidney failure, and circulatory abnormalities present. Conclusions: The most appropriate therapeutic option is liver transplantation, but not all patients can receive it, while accessing said management an option is drug treatment with vasoconstrictors and albumin.

Insuficiencia renal en cirrosis: revisión de la literatura

Contexto: en el curso de la enfermedad del paciente cirrótico, la insuficiencia renal es un evento de mal pronóstico. Objetivo: identificar en estos pacientes los factores de riesgo de IRA, tales como: presencia de procesos infecciosos, hipovolemia inducida por hemorragia, pérdidas gastrointestinales o renales y agentes nefrotóxicos, ya que conocer de su aparición es primordial para dar comienzo a las medidas terapéuticas y las acciones profilácticas. Metodología: se realizó una búsqueda bibliográfica en las bases de datos PubMed, EMBASE, Scopus y Google académico, usando los términos MeSH como insuficiencia renal aguda, creatinina, cirrosis hepática, síndrome hepatorenal. Se obtuvieron resultados entre artículos originales, metaanálisis, reportes de casos, series de casos y revisiones de la literatura, y se escogieron 16 documentos para la elaboración de esta revisión. Resultados: los nuevos criterios definidos por el Club Internacional de Ascitis (AKI-IAC), los cuales eliminan el gasto urinario, se determinan por un aumento de la creatinina sérica ≥ 0,3 mg/dL en menos de 48 horas y, mejoran el pronóstico, permitiendo realizar intervenciones oportunas. Conclusiones: la creatinina sigue siendo el biomarcador más utilizado en insuficiencia renal aguda (IRA), incluso en pacientes cirróticos, a pesar de sus múltiples limitaciones. Un criterio dinámico modificado a partir de los criterios de AKIN, se convierte en el patrón de oro para el diagnóstico de IRA en cirrosis.

Introduction: During the cirrhotic patient's disease, renal failure is a poor prognostic event. Purpose: Knowing the risk factors for AKI in these patients given by the presence of infectious processes, loss of fluids due to hemorrhage, gastrointestinal or kidney, and nephrotoxic agents are essential for initiating therapeutic measures and prophylactic actions. Methodology: A bibliographic search was carried out in the PubMed, EMBASE, Scopus and academic Google databases, using the terms MeSH acute renal failure, creatinine, liver cirrhosis, hepatorenal syndrome. Original articles, meta-analyzes, case reports, case series and literature reviews were obtained, choosing 16 documents for the preparation of this review. Results: The new criteria defined by the International Ascites Club (AKI-IAC), which eliminate urinary output, are determined by an increase in serum creatinine ≥ 0.3 mg / dL in less than 48 hours and improve the prognosis, allowing timely interventions. Conclusions: Creatinine continues to be the most widely used biomarker in AKI, even in cirrhotic patients, despite its multiple limitations. A dynamic criterion modified from the AKIN criteria becomes the gold standard for the diagnosis of AKI in cirrhosis.

Integrated traditional Chinese and Western medicine diagnosis and treatment of hepatorenal syndrome / 临床肝胆病杂志

As a common complication of end-stage liver disease, hepatorenal syndrome (HRS) is functional acute renal failure that occurs on the basis of severe liver diseases and is a group of clinical syndromes characterized by renal insufficiency, abnormal endogenous vascular substances, and hemodynamic changes of arterial circulation. The ideal treatment method for HRS is liver transplantation or simultaneous kidney transplantation, and optimization of drug and non-drug therapies is the key to the treatment of HRS. This article reviews the current status of the integrated traditional Chinese and Western medicine diagnosis and treatment of HRS.

Síndrome hepatorrenal en falla hepática aguda sobre crónica / Hepatorrenal syndrome in acute on chronic hepatic failure

Resumen La insuficiencia hepática aguda sobre crónica (ACLF, por su nombre en inglés: Acute-on-Chronic Liver Failure) es una entidad de reciente caracterización que se presenta como una descompensación aguda de una hepatopatía crónica, la cual puede ir asociada a falla en diferentes órganos y presentar una alta mortalidad. Su incidencia alcanza hasta un 30% de pacientes que consultan por complicaciones asociadas a cirrosis de base. Dentro de los factores precipitantes más frecuentes se encuentran las infecciones bacterianas, el alcoholismo y la reactivación de hepatitis virales; no obstante, hasta en un 40% de los casos no se identifica ningún factor precipitante. La fisiopatología de esta entidad aún es desconocida en cierta medida, pero se plantea la existencia de una respuesta inflamatoria excesiva en su desarrollo. No existe ningún tratamiento específico y su manejo se basa en el tratamiento para complicaciones asociadas, soporte y finalmente trasplante hepático. La disfunción renal es un hallazgo común en pacientes con enfermedad hepática. Se pensaba que el síndrome hepatorrenal era de carácter meramente funcional. Ahora, ante la evidencia de algún grado de daño tubular relacionado, se ha mejorado la comprensión de la fisiopatología de dicha entidad, lo que ha obligado recientemente a replantear los criterios diagnósticos y la clasificación de la enfermedad. Describimos el caso clínico de una paciente atendida en un centro hospitalario en la ciudad de Pereira, Risaralda. Ella presentó bacteriemia por cocos Gram positivos de origen no claro, lo que se consideró como el factor precipitante; tuvo deterioro clínico, con aparición de síndrome hepatorrenal y falla multiorgánica, lo que finalmente la llevo a la muerte, a pesar del manejo multidisciplinario.

Abstract Acute-on-chronic liver failure (ACLF) is a recently characterized entity that presents as an acute decompensation of chronic liver disease. It can be associated with failure in different organs and presents a high mortality rate. Its incidence reaches up to 30% on patients consulting for complications derived from cirrhosis. Among the most frequent precipitating factors, there are bacterial infections, alcoholism, and reactivation of viral hepatitis; however, in up to 40% of the cases, no precipitating factor is identified. The pathophysiology of this entity is still unknown to a certain extent, but the existence of an excessive inflammatory response in its development is suggested. There is no specific treatment and its management is based on treatment for associated complications, support, and finally liver transplantation. Kidney dysfunction is a common finding in patients with liver disease. The understanding of the pathophysiology of this entity, previously thought to be purely functional in nature, yet now given the evidence of some degree of related tubular damage, has improved and has recently entailed a rethink of the diagnostic criteria and the classification of the illness. We describe the clinical case of a patient treated at a hospital in the city of Pereira, Risaralda, who presented bacteremia due to Gram-positive cocci of unclear origin, considered as the precipitating factor. The patient had clinical deterioration, as well as the onset of hepatorenal syndrome and multi-organ failure, finally leading to death despite multidisciplinary treatment.

Mechanism and treatment of portal-systemic circulatory imbalance in hepatorenal syndrome / 临床肝胆病杂志

Hepatorenal syndrome (HRS) is a serious complication of end-stage liver disease, and its pathogenesis is associated with the systemic hemodynamic changes such as portal hypertension, arterial vasodilation, reduced cardiac output, reduced effective circulating blood volume, and renal artery contraction, as well as portal-systemic circulatory imbalance. For the treatment of HRS at present, vasoactive agents and interventional treatment are used to change systemic hemodynamics and portal-systemic circulatory imbalance, and early intervention can improve the prognosis of patients.

Predictive factors for the therapeutic effect of terlipressin combined with albumin in hepatorenal syndrome / 临床肝胆病杂志

Hepatorenal syndrome (HRS) is a serious complication of end-stage liver disease often observed in advanced liver cirrhosis patients with circulatory dysfunction and tends to have poor prognosis. At present, terlipressin combined with albumin is the preferred drug treatment regimen for HRS. Many studies have been conducted on the predictive factors for the therapeutic effect of terlipressin combined with albumin, but there lacks a comprehensive report of these studies. This article reviews the latest research advances in this disease and its treatment from the pathogenesis of HRS and the mechanism of action of drugs, as well as the research advances in the predictive factors for the therapeutic effect of terlipressin combined with albumin in terms of baseline data, changes after treatment, and treatment regimens. It is pointed out that early identification of factors that can help predict treatment response has important clinical significance.

Predictive factors for the therapeutic effect of terlipressin combined with albumin in hepatorenal syndrome / 临床肝胆病杂志

Hepatorenal syndrome (HRS) is a serious complication of end-stage liver disease often observed in advanced liver cirrhosis patients with circulatory dysfunction and tends to have poor prognosis. At present, terlipressin combined with albumin is the preferred drug treatment regimen for HRS. Many studies have been conducted on the predictive factors for the therapeutic effect of terlipressin combined with albumin, but there lacks a comprehensive report of these studies. This article reviews the latest research advances in this disease and its treatment from the pathogenesis of HRS and the mechanism of action of drugs, as well as the research advances in the predictive factors for the therapeutic effect of terlipressin combined with albumin in terms of baseline data, changes after treatment, and treatment regimens. It is pointed out that early identification of factors that can help predict treatment response has important clinical significance.

Principles for the prevention and treatment of complications related to cirrhotic portal hypertension / 临床肝胆病杂志

Liver cirrhosis is the most common cause of portal hypertension. Portal hypertension can cause complications such as esophageal and gastric varices, spontaneous bacterial peritonitis, hepatorenal syndrome, and hepatic encephalopathy. For the standardized diagnosis and treatment of portal hypertension, we should pay attention to primary diseases and whole-course treatment, emphasize whole-course chain management including early screening and early diagnosis, active prevention, and reasonable emergency treatment, and formulate individualized and precise prevention and treatment plans for patients.

Disfunción renal en el paciente cirrótico / Renal dysfunction in the cirrhotic patient

La disfunción renal es una complicación común en pacientes con cirrosis avanzada y está asociadaa un incremento significativo en la mortalidad. Este deterioro de la función renal puede ser reversible en algunos casos, si se identifica y se trata su etiología. La lesión renal aguda (LRA) de origen prerrenal y la necrosis tubular aguda (NTA) son las entidades más frecuentes en pacientes con enfermedad hepática crónica y cirrosis, constituyendo un desafío en los escenarios clínicos actuales. La aparición de nuevos biomarcadores como la lipocalina asociada a la gelatinasa de neutrófilos (NGAL), puede ser un factor determinante para esclarecer el origen de estas dos entidades. En la actualidad, la clasificación de la enfermedad renal establece que un aumento en la creatinina sérica basal >0,3 mg/dL dentro de las primeras 48 horas, o un incremento mayor al 50% desde la línea de base, son suficientes para definir lesión renal aguda, por lo cual, cambios leves en la creatinina sérica en un periodo corto de tiempo, contribuyen a una identificación temprana y previenen desenlaces negativos. Esta revisión de tema abordará la lesión renal aguda en cirrosis desde la fisiopatología, la clasificación actual según guías internacionales, los avances en biomarcadores y las principales etiologías, finalizando con un abordaje general y estrategias de prevención.

Kidney dysfunction is a common complication in patients with advanced cirrhosis and is associated with a significant increase in mortality. This deterioration of kidney function may be reversible in some cases, if its etiology is identified and treated. Acute kidney injury (AKI) of prerenal origin and acute tubular necrosis (ATN) are the most frequent entities in patients with chronic liver disease and cirrhosis, constituting a challenge in current clinical scenarios. The emergence of new biomarkers such as neutrophil gelatinase-associated lipocalin (NGAL), may be a determining factor in clarifying the origin of these two entities. Currently, the classification of renal disease establishes that an increase in basal serum creatinine >0,3 mg/dL within the first 48 hours, or an increase higher than 50% from the baseline, are enough to define acute kidney injury, therefore slight changes in serum creatinine in a short period of time contribute to an early identification and prevent negative outcomes. This literature review will address acute kidney injury in cirrhosis from its pathophysiology, current classification according to international guidelines, advances in biomarkers and the main etiologies associated with it, ending with a general approach and prevention strategies.

Características clínicas y complicaciones de la cirrosis hepática en una población de altura (Huancayo, 3250 m s. n. m.) / Clinical features and complications of liver cirrhosis in a high-altitude population (Huancayo, 3,250 m a.s.l.)

RESUMEN Objetivo La cirrosis hepática ocasiona significativa mortalidad y morbilidad. Esta investigación trata de determinar la presentación clínica, la etiología y las complicaciones de los pacientes con cirrosis hepática en una población que habita en una región de altura del Perú. Materiales y métodos Evaluación retrospectiva de la presentación clínica y las complicaciones de la cirrosis hepática. Se estudiaron 108 historias clínicas de pacientes cirróticos ingresados en el Servicio de Medicina del Hospital Nacional Ramiro Prialé Prialé de la ciudad de Huancayo entre el 2010 y el 2012. Resultados El promedio de edad de los pacientes fue de 60,50 años (rango 12-82 años) y el 62,90 % fueron varones. La etiología más frecuente fue la ingesta alcohólica (63,00 %) seguida por las hepatitis B y C crónicas (7,40 % y 2,80 %, respectivamente). El 58,30 % de los casos correspondía al estadio B de la clasificación de Child-Pugh y el 31,30 % se encontraba en estadio C. La manifestación clínica más frecuente fue la distensión abdominal (87,00 %). Las complicaciones más comunes fueron la ascitis (56,00 %), la encefalopatía hepática (47,20 %) y el síndrome hepatorrenal (8,30 %). Conclusiones La cirrosis alcohólica fue la etiología más común y las complicaciones más frecuentes fueron la ascitis y la encefalopatía hepática.

ABSTRACT Objective Liver cirrhosis is responsible for significant morbidity and mortality. This research aims to determine the clinical presentation, etiology and complications of patients with liver cirrhosis from a population living at a high altitude region in Peru. Materials and methods A retrospective study of the clinical presentation and complications of liver cirrhosis was conducted. One hundred eight (108) medical records of patients with liver cirrhosis admitted to the Internal Medicine Service of the Hospital Nacional Ramiro Prialé Prialé, Huancayo, were evaluated between 2010 and 2012. Results Patients' mean age was 60.5 years (range: 12-82 years) and 62.9 % were males. The most common etiology was alcohol consumption (63 %), followed by chronic hepatitis B and C (7.4 % and 2.8 %, respectively). Fifty-eight point three percent (58.3 %) of the patients had a Child-Pugh class B score and 31.30 % of them had a Child-Pugh class C score. The most frequent clinical presentation was abdominal distension (87 %). The most common complications were ascites (56 %), hepatic encephalopathy (47.2 %) and hepatorenal syndrome (8.3 %). Conclusions Alcoholic liver cirrhosis was the most common etiology. The most frequent complications were ascites and hepatic encephalopathy.

Research on clinical efficacy of liver transplantation for severe liver disease / 器官移植

@#Objective To explore the clinical efficacy of liver transplantation for severe liver disease. Methods The clinical data of 51 patients who underwent liver transplantation for severe liver disease were retrospectively analyzed. The general intraoperative conditions were observed, including operation duration, warm ischemia time, cold ischemia time, anhepatic phase, bleeding volume, blood transfusion volume, plasma transfusion volume and so on. The changes in indexes such as total bilirubin (TB), prothrombin time activity (PTA), and prothrombin time international normalized ratio (PT-INR) were observed before operation and at 3 d, 1 week and 2 weeks after operation. The postoperative survival and occurrence of complications were analyzed. The indexes that might affect the prognosis of patients with severe liver disease were analyzed by Cox regression analysis. Results For the 51 patients, operation duration, warm ischemia time and cold ischemia time was 8 (7, 9) h, 3 (2, 3) min and 6 (5, 8) h respectively, intraoperative anhepatic phase was 80 (70, 100) min, intraoperative bleeding volume was 1 000 (550, 1 500) mL, and intraoperative blood transfusion volume was 1 200 (200, 1 600) mL. Postoperative TB, PTA, PT-INR and other indexes improved significantly compared to those preoperatively. Among the 51 patients, 10 cases died, with the death causes of multiple organ failure and severe infection(7 cases), renal insufficiency (2 cases), and cardiovascular complications (1 case). Survival rates at 1 month and 1 year post-transplantation for patients with severe liver disease were 82% and 80%, respectively. Cox regression analysis suggested that abnormal preoperative PTA and PT-INR were the risk factors for post-transplantation death in patients with severe liver disease. Conclusions Liver transplantation significantly improves the survival rate for patients with severe liver disease, perioperative infection prevention and treatment as well as multiple organ function management play key roles in improving post-transplantation survival rate in patients with severe liver disease.

Research advances in integrated traditional Chinese and Western medicine therapy for hepatorenal syndrome / 临床肝胆病杂志

Hepatorenal syndrome (HRS) is a common complication of severe liver disease, with severe conditions and poor prognosis, and causes a great burden to both patients’ family and society. HRS has a complex pathogenesis, and Western medicine treatment has a limited therapeutic effect; therefore, integrated traditional Chinese and Western medicine therapy is a feasible treatment method with a good clinical effect. This article reviews the advances in the diagnosis and treatment of HRS in both modern and traditional medicine, so as to overcome this challenge as early as possible.

Acute kidney injury and hepatorenal syndrome in end-stage liver disease / 临床肝胆病杂志

Acute kidney injury (AKI) and hepatorenal syndrome (HRS) are serious complications in patients with end-stage liver disease, with renal injury as the main manifestation. They are interrelated, but also different from each other. There are several types of AKI, i.e., prerenal AKI, intrarenal or intrinsic AKI, and post-renal AKI, and type 1 HRS is considered a special type of AKI. There are different therapies for different types of AKI. With the improvement in the diagnostic criteria for AKI and chronic kidney disease in recent years, the diagnostic criteria and classification of HRS have also been updated. As for pathogenesis, systemic inflammation caused by intestinal bacterial translocation is attracting more and more attention. HRS was considered functional renal injury in the past, but recent evidence suggests the existence of structural injury. Vasoconstrictor combined with albumin is the main therapeutic drug for HRS. This article reviews the diagnosis and treatment of AKI in end-stage liver disease and the recent advances in the diagnostic criteria, classification, pathology, pathogenesis, and treatment of HRS.

Treatment of hepatorenal syndrome: Vasoconstriction or vasodilation? / 临床肝胆病杂志

Hepatorenal syndrome (HRS) is a serious complication that occurs in patients with decompensated cirrhosis or acute/chronic liver failure. The main pathological features of HRS include marked peripheral vasodilation and strong renal vasoconstriction, with rapid progression, unsatisfactory treatment response, and poor prognosis. Vasoconstrictors are mainly used in the pharmacotherapy for HRS, and at present, terlipressin combined with albumin is the first-line treatment method for HRS. Some drugs with a renal vasodilatory effect also show a potential therapeutic effect. This article reviews the latest research advances in the role and clinical application of vasoactive drugs in the treatment of HRS.

Advances in the treatment of hepatorenal syndrome / 临床肝胆病杂志

Hepatorenal syndrome is one of the major complications of decompensated cirrhosis secondary to the reduction in effective blood volume, imbalance of endogenous vasoactive substances, and the reduction in renal blood flow, with renal insufficiency as the main manifestation. In clinical practice, hepatorenal syndrome mainly manifests as the reduction in renal blood flow and glomerular filtration rate, with no marked changes in renal histology. The treatment of hepatorenal syndrome should start as soon as it is diagnosed. Current therapeutic modalities include the following: (1) general supportive therapies for primary diseases and predisposing factors; (2) pharmacotherapy, including albumin and vasoactive agents; (3) renal replacement therapy; (4) molecular adsorbent recirculating system; (5) transjugular intrahepatic portosystemic shunt; (6) liver transplantation. Liver transplantation is the optimal regimen for the treatment of hepatorenal syndrome, and the other methods including pharmacotherapy and renal replacement therapy are often used as transitional therapies before liver transplantation. Albumin combined with terlipressin is currently the preferred regimen of pharmacotherapy for hepatorenal syndrome. This article reviews the new concepts and advances in the treatment of hepatorenal syndrome.

Risk factors, diagnosis, and updated classification of hepatorenal syndrome / 临床肝胆病杂志

Hepatorenal syndrome (HRS) is a common complication of decompensated cirrhosis and is traditionally defined as progressive oliguria or anuria, azotemia, dilutional hyponatremia, and hyponatremia, while renal insufficiency without marked organic lesions in the kidney is the typical manifestation of HRS. Recent studies have found that besides the abnormalities in hemodynamics, inflammatory response, oxidative stress, and direct renal tubular toxicity of bile salts are jointly involved in the development and progression of HRS. HRS is not the only renal complication in patients with liver cirrhosis, and it is only a functional form of acute kidney injury (AKI). HRS meeting the criteria for AKI is called HRS-AKI, which is formerly known as HRS-Ⅰ type. For cirrhotic patients with acute kidney disease or chronic kidney disease, if they meet the criteria for HRS, they can be diagnosed with HRS-NAKI, which is formerly known as HRS-Ⅱ type. The most common risk factors for HRS are infection, digestive bleeding, and large-volume paracentesis without transfusion of human serum albumin for volume expansion.