Journal Reading: Medical Management of Hepatorenal Syndrome

Journal Reading:Medical Management of Hepatorenal SyndromeOleh:T. Tomy Saputra, S.KedI11108030Pembimbing:dr. Hadi Juanda, Sp.PDKepaniteraan Klinik Ilmu Penyakit DalamRST. Kartika Husada FK UNTANPontianak2015Introduction (1)Hepatorenal syndrome (HRS) is defined as the occurrence of renal dysfunction (functional renal failure) in a patient with end-stage liver cirrhosis in the absence of another identifiable cause of renal failure (renal pathology)Type 1 HRS & Type 2 HRSIntroduction (1)Type 1 HRS is characterized by a progressive impairment in renal function and a significant reduction in creatinine clearance within 12 weeks of presentation.Type 2 HRS is characterized by a reduction in glomerular filtration rate with an elevation of serum creatinine level, but it is fairly stable and is associated with a better outcome than that of Type 1 HRS.PatogenesisSirosis Hepatis + Hipertensi porta vasodilatasi arteri splanknik hipovolemi arterial sentral aktivasi (simpatis, RAA, ADH) vaso-konstriksi renal perubahan intrarenal ( vasokonstriktor; vasodilator ) vasokonstriksi renal ) sindrom hepatorenalResultsPrevention of HRSAssesement of intravascular volume in patients with cirrhosisFluid resuscitation in HRSParacentesisPharmacological treatment of HRSPrevention of HRSType 1 HRS patients should be closely monitored and precipitating factors including bacterial infection should be actively sought and treated (not graded).Drugs reducing renal perfusion or directly causing nephrotoxicity should be avoided when possibleExposure to contrast should be minimizedAssesement of intravascular volume in patients with cirrhosisExcessive administration of fluids should be avoided to prevent volume overloadFluid resuscitation in HRSPatients with HRS should be optimally resuscitated, with intravenous administration of albumin (initially 1 g of albumin/kg of body weight, up to a maximum of 100 g, followed by 2040 g/day) in combination with vasopressor therapy (1A), for up to 14 daysParacentesisIn cirrhotics, paracentesis is typically performed for symptomatic reliefPharmacological treatment of HRSVasoconstrictors: vasopressin, terlipressin, norepinephrine (noradrenaline), octreotide and midodrine, Other agents (Ornipressin)Albumin + terlipressin (vasopressin/ norepinephrine/octreotide and midodrine/Ornipressin) up to 14 days

ConclusionsAlthough the introduction of terlipressin and albumin has improved the outlook for patients with HRS, only ~50% of patients respond to therapyIn addition, the effects of changes in IAP on renal function in patients with HRS have not been explored and may need to be considered in terms of renal perfusion pressure, along with MAPTerima Kasih