T. Tomy Saputra, S.Ked/I11108030Kepaniteraan Klinik Ilmu Penyakit DalamRST. Kartika Husada FK Untan 2015

JOURNAL READINGMedical Management of Hepatorenal SyndromeAndrew Davenport, Jawad Ahmad, Ali Al-Khafaji, John A. Kellum, Yuri S. Genyk and Mitra K. Nadim

IntroductionHepatorenal 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). The International Ascites Club defined HRS in 1996, on the basis of a series of major inclusion criteria which were later revised in 2007 and subdivided into Types 1 and 2. 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.

ResultsGeneral management strategies:1. Prevention 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 possible. Exposure to contrast should be minimized.2. Assesement of intravascular volume in patients with cirrhosisExcessive administration of fluids should be avoided to prevent volume overload 3. Fluid 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 days.4. ParacentesisIn cirrhotics, paracentesis is typically performed for symptomatic relief5. Pharmacological 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

Conclusions1. Although the introduction of terlipressin and albumin has improved the outlook for patients with HRS, only ~50% of patients respond to therapy2. In 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 MAP