Hepatorenal syndrome. Studies of the effect of vascular volume and intraperitoneal pressure on renal and hepatic function.

Eleven patients with well-documented hepatorenal syndrome were studied by measurement of blood volume, glomerular filtration rate, renal plasma flow, plasma aldosterone concentration, renin substrate concentration, and plasma renin activity. They were then given 750 ml of stored plasma, 750 ml of fresh frozen plasma, and then an infusion of angiotensin II, in random order on successive days. Infusion of fresh frozen plasma improved function more than did stored plasma and in addition returned a very low filtration fraction toward normal. Angiotensin II infusion increased filtration fraction, but decreased glomerular filtration rate, renal plasma flow, and urine flow sharply. Patients were then given a daily infusion of 1,000 ml of fresh frozen plasma for seven to 18 days to expand the blood volume to supranormal levels as assayed by serial measurement of blood volume. Plasma aldosterone levels decreased to a normal range, glomerular filtration rate and renal plasma flow both increased, and urinary excretion of sodium and potassium both returned toward normal. The effect of intraperitoneal pressure was then studied by measuring glomerular filtration rate, renal plasma flow, pressure in the vena cava, hepatic vein free flow, and hepatic vein wedged pressure before, during, and after paracentesis to reduce the intraperitoneal pressure from 30 to 40 cm H2O to 12 to 17 cm H2O. Venous pressures moved parallel to ascitic fluid pressures, and glomerular filtration rate, renal plasma flow, and urine flow all improved sharply; then, as ascitic fluid continued to form, reducing vascular volume, urine flow, glomerular filtration rate, and renal plasma flow all decreased slowly. Six patients then underwent placement of a LeVeen shunt. Improvement in glomerular filtration rate and renal plasma flow and clinical condition was dramatic. During postoperative observation of up to two years, progressive improvement in hepatic function has occurred.

Effect of aerobic exercise training on patients with systemic arterial hypertension.

One hundred five patients with established diastolic hypertension were enrolled in an exercise program to examine the effect of aerobic conditioning on blood pressure. In four patients, the decrease in mean blood pressure was less than 5 mm Hg; in all others, there was a significant decline in arterial blood pressure. In 58 patients who were not taking drug medication in the pre-exercise period, mean blood pressure decreased by 15 mm Hg. Of 47 patients receiving drug therapy during the pre-exercise period, 24 were able to discontinue all medication. Mean blood pressure in this group fell from 116.9 +/- 6.5 mm Hg to 97.2 +/- 9.2 mm Hg as a result of exercise. In patients still taking antihypertensive drugs, mean pressure decreased from 120.9 +/- 28.8 mm Hg to 104.4 +/- 17.9 mm Hg after three months of exercise. It is concluded that in patients physically and emotionally able to exercise, a significant decline in blood pressure can be achieved.