Description of hepatorenal syndrome
As hepatorenal syndrome refers to functional impairment of the kidney, which is inherent in structural damage to liver tissue. Such involvement is more, but under the label include clearly defined disease that meets the diagnostic criteria.
Liver damage, which causes the syndrome, is a very advanced stage of liver cirrhosis with liver failure and severe portal hypertension (high pressure in the bloodstream portal vein-portal vein caused by congestion of the blood in the liver damage). In themselves, the kidneys are no or only minimal structural changes. These are mainly functional disability.
Causing problem is a fault in the bloodstream. When portal hypertension prevails in the blood supply to the digestive organs (ie. Splanchnic area) vasodilation (widening of blood vessels). Blood accumulate here, part of the fluids is filtered into the free abdominal cavity and formed exudate (ascites). As a reaction to the lack of blood circulation in the heart increases its activity. Now is also vasoconstriction (narrowing) of the afferent renal arteries thereby reducing blood flow through the kidneys (reduced renal filtration and urine production, body retains fluid to increase the volume of circulating blood). Adverse impact is kidney damage from hypoxia (reduced kidney of blood flow adequate oxygen supply).
Said vasoconstriction and vasodilation controls the substances produced by the body (vasoconstrictors, vasodilators). Imbalance in the production of these substances hepatorenal syndrome is considered the mechanism of renal impairment and subsequent disability structural.Examples here are the most important vasoconstrictors endothelin I and angiotensin II. The main vasodilators are nitric oxide (NO) and prostaglandins.
The disease is classified according to the rate and severity of the two types. Mutually also differ prognosis.
Hepatorenal syndrome type I
Rapidly progressive renal failure, progressive renal failure, rapid progressive renal failure, progressive renal dysfunction
Renal function was deteriorating rapidly, the failure occurs within two weeks. Present ascites does not respond to treatment. The body retains water and sodium. The prognosis is very serious,and most patients die with the latest treatment without a liver transplant within three months. Cause of death in most cases of renal failure, or severe hepatic encephalopathy (brain damage caused by the inability of the liver detoxification fulfill its function in the organism). When a liver transplant prognosis is slightly worse than in transplanted without hepatorenal syndrome. Type I can follow up on the second type of hepatorenal syndrome.
Hepatorenal syndrome type II
Mild type, moderate progressive renal failure, slowly progressive renal failure
It is a typical slow loss of kidney function. We can find him and periods of time without progression.There is also present ascites unresponsive to treatment. Very easily could pass into type I. The prognosis is also serious. Without a transplant, the average survival time of six to nine months.After transplantation prognosis is approximately the same as in type I.
Diagnosis of hepatorenal syndrome
For the diagnosis of hepatorenal syndrome it is important to rule out other reasons for the same clinical symptoms.
HRS is not shock-like state, is present bacterial infection capable of inducing the given symptoms, it is significant proteinuria (protein in urine). It is necessary to eliminate the ingestion of neurotoxic (toxic to the kidneys) substances or medication, then to exclude obstruction of the urinary tract.
It is impaired renal function. Kidney activity can be assessed by creatinine levels in blood serum and urine. At HRS is a high serum creatinine and very low filtering capacity of the kidneys (glomerular filtration rate). There is formed only a small amount of urine (oliguria).
Risk factors for hepatorenal syndrome
Not hepatorenal syndrome without liver disease. Thus, the risk is all the influences affecting the liver, such as alcohol and drug abuse. Risks also include lifestyle leading to infection withhepatitis B or C (drug addiction, sexual promiscuity). The risk is also relative to the possibility of hepatitis work of medical professionals. HRS can also cause paracentesis (needle conducted procedure in which the abdominal cavity is discharged from the ascites fluid) with the launch of a greater volume of fluid without concomitant administration of albumin.
Prevention of hepatorenal syndrome
The prevention is important to avoid the risk factors of liver damage. The first preventive measures are known for alcoholic hepatitis. Can be administered pentoxifylline (antagonist of the proinflammatory factor TNF-α), which only reduces the risk of HRS.
Symptoms of hepatorenal syndrome
In most cases, they are present mainly symptoms of liver failure. Symptoms of hepatorenal syndrome differed from simple hepatic failure are less noticeable. As a result of hepatic failure are present mainly edema and ascites, in more severe cases of esophageal varices. Ascites in case HRS usually unresponsive to treatment (ascites refractory to treatment). The patient is weak and tired. It has signs of dehydration (lack of fluids) such as dry tongue, severe thirst (while finding swelling!).In some cases the symptoms are present encephalopathy (brain damage are present mark disorientation). Heart rate is increased, but the blood pressure is low. It may be abdominal pain. Of the violations kidney function is added to low urine output (oliguria). In laboratory tests urine is characterized by low levels of sodium. Great predictive value of renal function have creatinine levels in blood serum and urine levels calculated from the known. Creatinine clearance (a very low value).
Treatment of hepatorenal syndrome
For symptomatic treatment is the most important drug terlipressin. This drug causes vasoconstriction in the splanchnic area decreases portal hypertension and thereby inducing a partial restriction conditions hepatorenal syndrome. Important is the administration of albumin (a protein, simply speaking draws fluid back into the blood vessels, thus induces the reverse process than when generating ascites). This is called. Rehydration own stocks. Carried repeat paracentesis for the elimination or at least reduction of ascites. For treatment, it is important to try to maintain the balance of the internal environment (such as the level of vital ions within safe limits).
Do symptomatic treatment comes the introduction of TIPS (transjugular intrahepatic portosystemic shunt). For operational solutions intractable portal hypertension, of forming a coupling between portal and systemic vascular system, which part of the blood bypasses the liver, and those are thus somewhat easier. Can have side effects induced nedetoxikovanou blood that does not pass through the liver.
The only causal (removing the cause), hepatorenal syndrome therapies currently liver transplantation.
How can I help myself
The patient must strictly avoid all effects that could worsen the disease (especially alcohol) and must comply with the restrictions indicated before liver transplantation.
Complications hepatorenal syndrome
Major complications hepatorenal syndrome is a need for a liver transplant. Despite intensive treatment increasingly large proportion of patients without transplants died within a few months.Unfortunately for transplantation is a useful minority of patients with HRS.
Other names: HRS Hepatorenal syndrome, rapidly progressive renal failure, progressive renal failure, rapid progressive renal failure, progressive renal dysfunction, slowly progressive renal failure, moderate progressive renal failure