Arritmias e alterações cardíacas no paciente cirrótico / Arrhythmias and cardiac alterations in the cirrhotic patient

No Brasil, a cirrose é um problema de saúde pública, que afeta aproximadamente 2 milhões de pessoas. As causas mais comuns são a doença hepática alcoólica, as hepatites virais e a doença hepática não alcoólica. A relação entre desordens cardíacas e hepatopatias é descrita na literatura, e a mais importante delas é o prolongamento do intervalo QT. A cirrose, independente de sua causa, é uma patologia frequentemente encontrada na população brasileira. Por este motivo, elucidar dados referentes às arritmias cardíacas em pacientes cirróticos é de grande importância dentro do estudo desta subpopulação. O objetivo deste artigo é fazer uma revisão de literatura com as informações referentes a epidemiologia, fisiopatologia, fatores de risco e prognóstico para as arritmias cardíacas em portadores de cirrose. (AU)

In Brazil, cirrhosis is a public health problem affecting approximately 2 million people. The most common causes are alcoholic liver disease, viral hepatitis, and non-alcoholic liver disease. The relationship between cardiac disorders and liver diseases is described in the literature, and the most important one is the QT interval prolongation. Cirrhosis, regardless of its causes, is a pathology that is frequently found in the Brazilian population. For this reason, elucidating data regarding cardiac arrhythmias in cirrhotic patients is of great importance within the study of this subpopulation. The aim of this article is to review the literature with information on the epidemiology, pathophysiology, risk factors, and prognosis for cardiac arrhythmias in patients with cirrhosis. (AU)

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.

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.

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: pathophysiology and treatment.

The hepatorenal syndrome (HRS) is a unique form of acute renal failure with entirely normal renal histology in advanced liver disease. Its diagnosis is made by exclusion of all causes of renal failure and by all the five major criteria as set by the International Ascites Club. The presence of hepatomegaly, poor nutritional status, and oesophageal varices at endoscopy are associated with a high risk of HRS. The liver tests, the Child-Pugh score, are of no value in prediction of its occurrence. Contraction of the effective blood volume, which may lead to renal hypoperfusion with preferential renal cortical ischaemia, is proposed pathogenesis of the condition. Because understanding of the pathogenesis of HRS is incomplete, therapy is supportive only. Optimal fluid management is vital as there is almost invariably a reduction in effective arterial blood volume. Dopamine, frusemide and haemofiltration may be helpful in management of fluid overload but do not affect renal function. TIPS has been used successfully in small series of patients. The vasopressin analog also has been used with early excellent response. The treatment of HRS has been discouraging and the only proven cure for HRS is liver transplantation at this point of time.

Renal blood flow in cirrhotic patients and hepatorenal syndrome [HRS]

This work aimed to assess the effect of liver cirrhosis and ascites on renal blood flow. The study included 40 consecutive patients with liver cirrhosis divided into two groups according to presence or absence of renal dysfunction in addition to ten normal volunteers taken as controls. All patients were subjected to clinical, laboratory, ultrasonographic, duplex study on renal artery and isotopic study for the estimation of total effective renal plasma flow [ERPF]. The results showed that the mean total ERPF was significantly lower in group B [HRS] compared to group A [cirrhotics]. The mean ERPF/CO was significantly lower in group B compared with group A. It was concluded that patients with HRS showed a marked diminution in total ERPF and ERPF/CO when compared with normal volunteers, while cirrhotic patients only showed mild diminution in total ERPF and ERPF/CO compared with the volunteers. However, renal blood flow when measured by duplex showed a similar elevation in renal vascular resistance in both HRS and cirrhotics

Síndrome hepatorrenal / Hepatorenal syndrome

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

Problemas renales de la cirrosis

Cirrhosis of the liver is a common entity frequently seen by the clinician only after initiation of edema or ascitis. Renal problems have been described for many years associated to all types of cirrhosis, and are responsible for many abnormalities of water and electrolytes seen in these patients. One of the most remarkable renal abnormalities is sodium retention, with urinary excretion (Una V) of less than 10 mEq/1. This fact explains the common appearance of edema and ascitis even in the early states of cirrhosis. For many years two main theories have been postulated in order to explain this avid sodium retention: 1) The "underfill theory" states that the initial event is a state of peripheral vasodilatation that causes ineffective plasma volume and sodium retention by the kidney, meaning that the sodium retention is a secondary event. 2) the "overflow theory" in contrast, emphasizes that the primary event is sodium retention by the kidney, with secondary expansion of plasma volume and associated sequestration of fluid in the abdomen due to portal hypertension and a reduction of the colloid-osmotic pressure. Recent evidence is suggestive that both theories play a significant role in the avid sodium retention of cirrhosis. In order to explain the sodium retention by the kidney the following humoral factors have been postulated: increased secretion and decreased degradation of aldosterone, decreased production of prostaglandin E, increased secretion of catecholamines, decreased response to the natriuretic atrial factor and abnormalities of the kalikrein-kinin system. Although some studies have shown abnormalities in the handling of water by the kidney, most of the evidence suggest that it is due to the sodium retention...

Síndrome hépato-renal / Hepatorenal syndrome

A síndrome hépato-renal ocorre geralmente em pacientes cirróticos descompensados acompanhada de ascite e icterícia e sem comprovaçäo de outras forma de insuficiência renal. A síndrome produz intensa vasoconstriçäo renal com conseqüente reduçäo do fluxo sangüíneo e diminuiçäo da filtraçäo glomerular. Ocorre em 17% dos cirrótico internados e em cerca de 50% dos que morrem complicados com ascite. O início da síndrome hépato-renal (SHR) pode ser lento ou rápido e precipitado por sangramento digestivo, uso excessivo de diuréticos, uso de anti-inflamatórios näo corticoide, drogas nefrotóxicas e infecçöes. Há três tipos de SHR, uma de evoluçäo rápida, habitual e estável. Os dois primeiros levando a óbito em curto espaço de tempo. A ascite é de difícil resoluçäo e o quadro evolui na maioria das vezes com encefalopatia, hipotensäo, oligúria e óbito. Näo existe tratametno específico para a SHR. É necessário afastar ou tratar fatores desencadeantes, tais como hemorragia digestiva, sepse, distúrbios hidro-eletroliticos e uso de drogas. O transplante hepático pode ser realizado com mortalidade elevada notadamente nos portadores de insuficiência renal

Síndrome hepatorrenal / Hepatorrenal syndrome

The clinical and laboratory of this syndrome are reviewed, with special emphasis upon different mechanisms that may be involved in its pathogenesis