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Hepatorenal Syndrome SMF ILMU PENYAKIT DALAM RSAY METRO/FK UNILA JOHN ELFRAN SIHOMBING Pembimbing: dr. Ronald David Martua Nababan, S

Hepatorenal Syndrome John

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Page 1: Hepatorenal Syndrome John

Hepatorenal Syndrome

SMF ILMU PENYAKIT DALAM

RSAY METRO/FK UNILA

JOHN ELFRAN SIHOMBING

Pembimbing: dr. Ronald David Martua Nababan, Sp.PD

Page 2: Hepatorenal Syndrome John

Cirrhosis Evolves Clinically From Compensated to Decompensated Stage

• Compensated cirrhosis• Cirrhosis without complications• Median survival >12 years

• Decompensated cirrhosis• Cirrhosis with complications: ascites

(±HRS), variceal hemorrhage, jaundice, or encephalopathy

• Annual rate of decompensation of 4-5%• Median survival ~1.5 years

Page 3: Hepatorenal Syndrome John

Pathogenesis of Ascites in Cirrhosis

↑ intrahepatic resistance

cirrhosis

Portal hypertension

Splanchnic vasodilatation

↓ Effective arterial blood volume

Activation of neurohumoral systems

Sodium retension

ascites

(Boyer, T.D.)

Page 4: Hepatorenal Syndrome John

Common Pathogenesis in Refractory Ascites, Hyponatremia, and HRS

↑ ↑ intrahepatic resistance

cirrhosis

Portal hypertension

Splanchnic vasodilatation

↓ ↓ Effective arterial blood volume

Activation of neurohumoral systems

Sodium retension

ascites

Water retention Renal vasoconstriction

Refractory Ascites Hiponatremia HRS(Boyer, T.D.)

Page 5: Hepatorenal Syndrome John

DefinisiSindrom hepatorenal (SHR)

adalah gangguan fungsi ginjal sekunder pada penyakit hati tingkat berat, baik akut maupun kronis, yang bersifat fungsional dan progresif (Setiawan dan Hernomo, 2006).

Page 6: Hepatorenal Syndrome John

Hepatorenal syndrome

Kriteria Mayor berdasarkan International Ascites Club

• Hepatic insufficiency and portal hypertension

• Low GFR (< 40 ml/min) or creatinine > 1.5 mg/dl

• No shock, bacterial infection, fluid loss and current or recent treatment with nephrotoxic drugs

• No sustained improvement after withdrawal of diuretics and infusion of 1.5 liters of saline

• Proteinuria of < 500 mg/dl and negative renal ultrasound

Page 7: Hepatorenal Syndrome John

Hepatorenal syndromeAdditional Criteria

Kriteria Minor berdasarkan International Ascites Club

• Urine volume < 500 ml/d• Urine sodium < 10 meq/L• Urine osmolality > plasma• Urine RBCs < 50/hpf• Serum sodium < 130 meq/L

*Semua kriteria mayor harus dijumpai dalam menegakkan diagnosa Sindroma Hepatorenal, sedangkan kriteria tambahan merupakan pendukung untuk diagnosa Sindroma Hepatorenal

Page 8: Hepatorenal Syndrome John

Hepatorenal syndrome

• Type 1-Doubling of serum creatinine to > 2.5 mg/dl in less than 2 weeks.

• Type 2-Moderate but steady decrease in renal function to creatinine > 2.5 mg/dl.

Page 9: Hepatorenal Syndrome John

Who Develops HRS?

Cirrhotic patients with ascites• May be preceded by precipitating factor

• Spontaneous bacterial peritonitis (SBP)

• Sepsis• Total paracentesis• Upper GI hemorrhage

Patients with acute alcoholic hepatitisPatients with acute liver failure

Page 10: Hepatorenal Syndrome John

Treatment of HRS General Measures

• Stop all diuretics• Look for nephrotoxic drugs• Examine urine for white cells and casts• Perform renal ultrasound• Give 1.5 liters saline/albumin• Treat infection

Page 11: Hepatorenal Syndrome John

Pharmacologic Therapy

Page 12: Hepatorenal Syndrome John

Vasoconstrictors Plus Albumin for HRS

↑ intrahepatic resistance

cirrhosis

Portal hypertension

Splanchnic vasodilatation

↓ Effective arterial blood volume

Activation of neurohumoral systems

Renal vasoconstriction

HRS

vasoconstrictors

Albumin

+

(Boyer, T.D.)

Page 13: Hepatorenal Syndrome John

Terlipressin

• Synthetic 12-aminoacid peptide• Pro-drug, with pharmacologic activityof its own• Constrictive activity via V1-receptors

• vascular & extravascular smooth muscle cells

• Splanchnic vasoconstriction • ↓portal flow • ↓portal pressure

• Systemic vasoconstriction • ↑effective blood volume • ↓renin and angiotensin

renal vasodilatation

improvement in serum creatinine

Page 14: Hepatorenal Syndrome John

Non-pharmacologic Therapy

• Dialysis

• TIPS (Transjugular intrahepatic portosystemic shunt)

• Liver Transplantation

Page 15: Hepatorenal Syndrome John

Patogenesis Sindrom Hepatorenal pada Sirosis, Berdasarkan Teori Vasodilatasi Arterial, dan Intervensi Terapi Efektif

(Glines, 2003)

Page 16: Hepatorenal Syndrome John

DAFTAR PUSTAKA

Boyer, T.D. Hepatorenal Syndrome. University of Arizona. USA.

Glines, Pere. 2003. Hepatorenal Syndrome. Lancet 2003; 362: 1819-1826. Didapat dari www.med.upenn.edu/gastro/documents/LancetHRS.pdf

Setiawan, P. B, Hernomo K. Sindrom Hepatorenal. Dalam: ed. Sudoyo, Ari Wdkk. Buku Ajar Ilmu Penyakit Dalam Jilid I Edisi IV. Jakarta: Pusat Penerbitan Departemen Ilmu Penyakit Dalam Fakultas Kedokteran Universitas In-donesia; 2006. Hal 452 – 454

Page 17: Hepatorenal Syndrome John

TERIMA KASIH