Síndrome hepatorrenal: abordaje clínico y estrategia terapéutica / Hepatorenal Syndrome: clinical approach and therapeutic strate

El síndrome hepatorrenal (SHR) se define como el desarrollo de injuria renalen un paciente cirrótico en ausencia de una causa identificable que la explique. De acuerdo con la velocidad de instalación y la severidad de la fallarenal, se describen 2 tipos (tipo I y tipo II). El SHR tipo I se caracteriza por un rápido y progresivo deterioro de la función renal con un pronóstico ominoso, mientras que en el SHR tipo II el desarrollo de la falla renal es de instalación más insidiosa y de menor gravedad, pero de todas formas con un mal pronóstico a corto plazo. La media de sobrevida global de esta entidad es deaproximadamente 3 meses (2 semanas para el SHR tipo I vs. 4 a 6 meses para el SHR tipo II), aunque la implementación de estrategias terapéuticas tiene un claro impacto en el pronóstico. Dado que no existen pruebas de laboratorio específicas para su diagnóstico, éste se basa en datos clínico-analíticos y en la exclusión de otras causas de injuria renal en este contexto. El tratamiento definitivo de esta entidad es el trasplante hepático, siendo los fármacos vasoconstrictores sistémicos análogos de la vasopresina en combinación con albúmina la terapéutica puente de elección a él

Hepatorenal syndrome (HRS) is defined as the onset of renal failure without an identifiable cause in a cirrhotic patient. According with the installation speed and the severity of the renal failure, two types are described: type I and type II. Type I is characterized by a rapid and progressive deterioration of renal function with an ominous prognosis. Type II, presents with an insidious and less severe development of renal failure, but always bears a poor short-term prognosis. Although the implementation of therapeutic strategies has a clear impact on the prognosis, the median overall survival of these patients is approximately 3 months (2 weeks for type I HRS vs. 4 to 6 months for type II HRS). Since there are no specific tests for the diagnosis, it is based on a combination of clinical and laboratory data as well as the exclusion of other kinds of renal injury. Systemic vasoconstrictors drugs analogues of vasopressin combined with albumin are the treatment of choice before liver transplantation, which constitutes the definitive treatment of this entity.

Síndrome hepatorenal: patogénesis y tratamiento / Hepatorenal syndrome: pathogenesis and treatment

El Síndrome Hepatorenal (SHR) es una insuficiencia renal aguda funcional y reversible, que se desarrolla en pacientes con cirrosis hepática descompensada o en insuficiencia hepática aguda severa. La característica principal del SHR es la intensa vasoconstricción renal causada por la interacción entre alteraciones hemodinámicas a nivel sistémico y portal. El aumento del volumen intravascular y un prolongado tratamiento con fármacos vasoconstrictores pueden revertir la falla renal en un porcentaje significativo de pacientes. El SHR Tipo 2, el más frecuente, generalmente presenta una evolución lenta y un mejor pronóstico que el SHR Tipo 1. La terapia vasoconstrictora con terlipresina asociado a albúmina es el tratamiento de elección en pacientes con SHR. Apesar del avance en las diferentes estrategias terapéuticas, el pronóstico a largo plazo es aún pobre y depende generalmente del grado de reversibilidad de la enfermedad hepática asociada o del acceso al trasplante hepático. En la presente revisión se discutirán los avances más recientes en el diagnóstico, patogénesis y tratamiento del SHR.

The Hepatorenal Syndrome (HRS) is a functional and reversible form of acute renal failure, which develops in decompensated cirrhosis or acute liver failure. The distinctive hallmark feature of HRS is the intense renal vasoconstriction caused by interactions between systemic and portal hemodynamics. Increasing intravascular volume and prolonged treatment with vasoconstrictors drugs reverses renal failure in a significant proportion of patients. Type 2 HRS, the most frequent, generally follows a slower course and has a better prognosis than Type 1 HRS. Vasopressor therapy with terlipressin plus intravenous albumin is the medical treatment of choice for patients with HRS. Despite improvements in the therapeutic strategies, long term prognosis is still poor and generally depends on the degree of reversibility of the underlying liver disease or access to liver transplantation. In the present review, the most recent advances in diagnosis, pathophysiology, and treatment of HRS are discussed.

Type 2 Hepatorenal Syndrome in a Cirrhotic Patient Who Underwent Gastric Cancer Surgery / 대한소화기학회지

No abstract available.

Hepatorenal syndrome: an update

Hepatorenal syndrome (HRS) is the development of renal failure in patients with chronic previous liver disease, without clinical or laboratory evidence of previous kidney disease. It affects up to 18 percent of cirrhotic patients with ascites during the first year of follow-up, reaching 39 percent in five years and presenting a survival of about two weeks after its establishment. HRS diagnosis is based on clinical and laboratory data. The occurrence of this syndrome is related to the mechanism for ascites development, involving vasoconstriction, low renal perfusion, water and sodium retention, increased plasma volume, and consequent overflow at the splanchnic level. Renal vasoactive mediators like endothelin 1, thromboxane A2, and leukotrienes are also involved in the genesis of this syndrome, which culminates in functional renal insufficiency. The treatment of choice can be pharmacological or surgical, although liver transplantation is the only permanent and effective treatment, with a four-year survival rate of up to 60 percent. Liver function recovery is usually followed by renal failure reversion. Early diagnosis and timely therapeutics can increase life expectancy for these patients while they are waiting for liver transplantation as a definitive treatment.

A síndrome hepatorrenal (SHR) é o desenvolvimento do quadro de insuficiência renal em pacientes com doença hepática crônica prévia sem evidências clínica ou laboratorial de nefropatia prévia. Atinge até 18 por cento dos pacientes cirróticos com ascite em um ano, chegando a 39 por cento em cinco anos, com uma sobrevida média em torno de duas semanas após estabelecido o quadro. O diagnóstico da SHR baseia-se em critérios clínicos e laboratoriais. Seu aparecimento está relacionado ao mecanismo de formação de ascite, que envolve vasoconstrição e hipofluxo renal, retenção de água e sódio, aumento do volume plasmático, e conseqüentemente hiperfluxo no território esplâncnico. Mediadores vasoativos renais e humorais, como a endotelina 1, tromboxano A2 e leucotrienos, estão ainda envolvidos na gênese desta síndrome que culmina com insuficiência renal funcional. O tratamento preconizado da SHR pode ser farmacológico ou cirúrgico, sendo o transplante de fígado o único efetivo e permanente, com sobrevida de até 60 por cento em quatro anos. Após melhora da função hepática, geralmente há a reversão da insuficiência renal. O diagnóstico precoce e a rápida terapêutica podem ampliar a expectativa de vida destes hepatopatas enquanto se aguarda o transplante hepático para seu tratamento definitivo.

Syndrome hepatorrenal / Hepatorenal syndrome

Alterações da função renal e do metabolismo hidrossalino são comuns em pacientes com doença hepática. As alterações renais variam de importância e abrangem desde condições leves até aquelas que colocam a vida em risco. Há várias síndromes azotêmicas em cirróticos; no entanto, a síndrome hepatorrenal é a que chama mais atenção nesse grupo de pacientes. O autor revisa esta síndrome de maneira clara, objetiva e atualizada

Recent advances in hepatorenal syndrome.

Hepatorenal syndrome is a common complication of advanced cirrhosis, characterized by renal failure and major disturbances in circulatory function. Renal failure is caused by intense vasoconstriction of the renal circulation. The syndrome is probably the final consequence of extreme underfilling of the arterial circulation secondary to arterial vasodilatation in the splanchninc vascular bed. The diagnosis of HRS is currently based on the exclusion of other causes of renal failure. The prognosis is very poor, particularly when there is rapidly progressive renal failure (type 1). Liver transplantation is the best option in patients without contraindications to the procedure, but it is not always possible owing to the short survival expectancy. Therapies introduced during the past few years, such a vasoconstrictor drugs (vasopressin analogues, mu-adrenergic agonist) or the transjugular intrahepatic portosystemic shunt, are effective in improving renal function. Nevertheless, liver transplantation should still be done in suitable patients even after improvement of renal function because the outcome of HRS is poor.

Síndrome hepatorrenal / Hepatorenal Syndrome

Os autores fazem uma revisão bibliográfica sobre as definições, identificação e classificação da Síndrome Hepatorrenal. Através de uma base de dados atualizada, expõem-se as abordagens terapêuticas da patologia

Hepatorenal syndrome.

Hepatorenal syndrome is a life-threatening complication occurring commonly in cirrhosis liver and rarely in acute liver failure. It can be precipitated by shock, infection, surgery, large volume paracentesis or nephrotoxic drugs. Type I hepatorenal syndrome which usually develops over acute liver failure is rapidly progressive and has poor outcome. Type II hepatorenal syndrome is usually associated with refractory ascites and is slowly progressive with relatively good prognosis. Peripheral vasodilation with intrarenal vasoconstriction is the main pathophysiologic change. Diagnostic criteria, ascertained by international ascites club, is helpful to reach at a proper diagnosis. Management includes pharmacologic therapy to induce splanchnic vasoconstriction which improve renal circulation. Dopamine, vasopressin analogs (ornipressin and terlipressin), midodrine, noradrenaline have been used mainly as a bridge to the liver transplant or in anticipation of improvement in hepatic function. The molecular adsorbent recycling system (MARS) have been recently used in patients with hepatorenal syndrome. Transjugular intrahepatic portosystemic shunt is also another modality which has been used as a bridge to liver transplant in such patients.

Ecotomografía doppler arterial intrarrenal en pacientes cirróticos con ascitis, con y sin síndrome hepatorrenal / Intrarenal arterial doppler ultrasonography in cirrhotic patients with ascites, with and without hepatorenal syndrome

Background: The pathophysiological hallmark of the hepatorenal syndrome (HRS) is renal vasoconstriction. Doppler ultrasonography can be used to assess the vascular resistance in small renal intraparenchymal vessels through analysis of the Doppler waveform by a parameter termed Resistive Index (RI). We postulated that the RI could be important for the diagnosis and prognosis of HRS. Aims: to assess the RI in cirrhotic patients with ascites, with and without HRS. Patients and methods: We studied 48 cirrhotics with ascites, of whom 12 were with and 36 without HRS and other 23 were normal subjects. We measured the intrarenal arterial RI (Resistive index = Peak systolic velocity - Minimum diastolic velocity/Peak systolic velocity) with color Doppler ultrasonography after visualization of interlobular or arcuate arteries. It was considered abnormal when higher than 0.70. Results: The RI values, mean and SD) were: normal subjects: 0.58 ñ 0.05, cirrhotics with ascites: 0.65 ñ 0.05 and cirrhotics with ascites and HRS: 0.78 ñ 0.11. Patients with HRS had significantly higher values than those without HRS (p < 0.001). The Relative Risk of developing the HRS in patients with a RI ü 0.70 were 3.32 (CI 95 percent = 1.79 - 6.2) Conclusions: The RI was useful in patients with cirrhosis and ascites for the prognosis of HRS and could suggest diagnosis of HRS with values of 0.78 or higher, if other clinical conditions that produce renal vasoconstriction are excluded

Leptospirosis in the causation of hepato-renal syndrome in and around Pune.

Fifty cases of hepato-renal dysfunction of unknown etiology were studied over a two-year period. Urine samples were examined microscopically and cultured for Leptospira. Serum samples were examined for antibodies against Leptospira by the Macroscopic slide agglutination test (MSAT). Seventeen out of fifty patients (34%) showed evidence of Leptospiral infection by at least two diagnostic techniques used. 15/17 i.e. 88.2% were positive by dark ground microscopy, 7/17 were diagnosed by culture technique and 16/17 i.e. 94% were confirmed by serology. There was a good correlation between Microscopic agglutination test (MAT) and MSAT. Thus Leptospires seem to play a major role in the causation of hepato-renal dysfunction in and around Pune, Maharashtra.

Síndrome hepatorrenal / Hepatorenal syndrome

In this article the author presents the definition, clinical features, laboratory findings, patho-physiology and management of the hepatorrenal syndrome