Diagnosis of Hepatorenal Syndrome
肝肾综合征诊断
(4) absence of shock; (5) no current or recent treatment with nephrotoxic drugs; (6) absence of parenchymal kidney disease as indicated by proteinuria 500 mg/day, microhematuria (50 red blood cells per high power field), and/or abnormal renal ultrasonography.
- Marked renal vasoconstriction - Marked reduction of GFR
肾血管强烈收缩
肾小球滤过率明显降低 钠水排泄损伤
- Impaired sodium and water excretion
Circulatory abnormalities 循环异常
- Arterial hypotension. Low systemic vascular resistance
1. Guevara M, Ginès P, Fernández-Esparrach G, et al. Reversibility of hepatorenal syndrome by prolonged administra-tion of ornipressin and plasma volume expansion. Hepatology 1998;27:35-41. 2. Gülberg V, Bilzer M, Gerbes AL. Longterm therapy and retreatment of hepatorenal syndrome type 1 with ornipressin and dopamine. Hepatology 1999;30:870-5. 3. Kiser TH, Fish DN, Obritsch MD, Jung R, MacLaren R, Parikh CR. Vasopressin, not octreotide, may be beneficial in the treatment of hepatorenal syndrome: a retrospective study. Nephrol Dial Transplant 2005;20:1813-20. 4. Moreau R, Durand F, Poynard T, et al. Terlipressin in patients with cirrhosis and type 1 hepatorenal syndrome: a retrospective multicenter study. Gastroenterology 2002;122:923-30. 5. Fabrizi F, Dixit V, Martin P. Metaanalysis: terlipressin therapy for hepatorenal syndrome. Aliment Pharmacol Ther 2006;24:935-44. 6. Gluud LL, Kjaer MS, Christensen E. Terlipressin for hepatorenal syndrome. Cochrane Database Syst Rev 2006;4: CD005162. 7. Sanyal AJ, Boyer T, Garcia-Tsao G, et al. A randomized, prospective, doubleblind, placebo-controlled Trial of terlipressin for type 1 hepatorenal syndrome. Gastroenterology 2008;134:1360-8. 8. Martín-Llahí M, Pépin MN, Guevara M, et al. Terlipressin and albumin vs albumin in patients with cirrhosis and hepatorenal syndrome: a randomized study. Gastroenterology 2008;134:1352-9 9. Sergio Neri ,Davide Pulvirenti ,Mariano Malaguarnera et al.Terlipressin and Albumin in Patients with Cirrhosis and Type I Hepatorenal Syndrome. Dig Dis Sci 2008, 53:830–835
肝肾综合征
特利加压素治疗及评价
上海交通大学瑞金医院 吴云林
肝肾综合征
（Hepatorenal Syndrome，HRS）
重症肝病患者发生一种严重并发症。 功能性肾功能受损 肾小球滤过率降低 显著心血管功能异常 内源血管活性系统过度 活跃 少尿 无尿 氮质血症 低血钠 低尿钠 等
Pathogenesis of Circulatory Abnormalities and Renal Failure in Cirrhosis
肝肾综合征的临床分型
Type I
rapidly progressive reduction in renal function as defined by a doubling of the initial serum creatinine to a level 2.5 mg/dL or a 50% reduction of the initial 24-hour creatinine clearance to a level 20 mL/minute in less than 2 weeks.
Salerno F et al, the international ascites club. Gut 2007;56:1310-1318.
Pathophysiology of HRS and potential therapeutic interventions
Turban S, Thuluvath PJ, Atta MG. Hepatorenal syndrome. World J Gastroenterol 2007; 13(30): 4046-4055
Clinical Features of type I HRS
1、rapidly progressive renal failure serum creatinine ：doubling of the initial level / greater than 226 μmol/L (2.5 mg/dL) in less than 2 weeks 2、spontaneously ascites 3、precipitating factor：overdiuresis, large-volume paracentesis, gastrointestinal bleed, sepsis 4、arterial hypotension and activation endogenous compensatory vasoconstrictor systems 5、Multiorgan failure is common, and the prognosis, if untreated, is very poor, with a median survival of less than 10 days
Type II
does not have a rapidly progressive course and is a common cause of death in patients who do not die of other complications of cirrhosis.
Salerno F et al, international ascites club. Gut 2007;56:1310-1318
Management of the Hepatorenal Syndrome（肝肾综合征治疗）
1、vasoconstrictor drugs
血管收缩药物
- renal vasodilators: dopamine or prostaglandins is ineffective - vasopressin analogues (e.g., terlipressin) - initial therapy - alpha-adrenergic agonists ：norepinephrine and midodrine - Other：octreotide
N Engl J Med 2009;361:1279-90
Pathophysiology of Hepatorenal Syndrome
Wong, et al. Liver ,2008,10:22-29
Pathophysiology of Hepatorenal Syndrome
Renal abnormalities 肾脏异常
2、albumin
白蛋白
N Engl J Med 20 MD, FRCP, FRCPC，Hepatorenal Syndrome: Current Management. Liver，2008，10：22-29
Positive conclusions of terlipressin
Florence Wong,et al.Hepatorenal Syndrome: Current Management. Liver 2008, 10:22–29
Diagnosis of Hepatorenal Syndrome
肝肾综合征诊断
major criteria
(1) cirrhosis with ascites; (2) serum creatinine ＞1.5 mg/dL; (3) no improvement of serum creatinine (decrease to a level of 1.5 mg/dL or less) after at least 2 days with diuretic withdrawal and volume expansion with albumin (The recommended dose of albumin is 1 g/kg body weight/day up to a maximum of 100 g/day);