Renal dysfunction is common in liver diseases,either as part of multiorgan involvement in acute illness or secondary to advanced liver disease.The presence of renal impairment in both groups is a poor prognostic indic...Renal dysfunction is common in liver diseases,either as part of multiorgan involvement in acute illness or secondary to advanced liver disease.The presence of renal impairment in both groups is a poor prognostic indicator.Renal failure is often multifactorial and can present as pre-renal or intrinsic renal dysfunction.Obstructive or post renal dysfunction only rarely complicates liver disease.Hepatorenal syndrome(HRS)is a unique form of renal failure associated with advanced liver disease or cirrhosis,and is characterized by functional renal impairment without significant changes in renal histology.Irrespective of the type of renal failure,renal hypoperfusion is the central pathogenetic mechanism,due either to reduced perfusion pressure or increased renal vascular resistance.Volume expansion,avoidance of precipitating factors and treatment of underlying liver disease constitute the mainstay of therapy to prevent and reverse renal impairment.Splanchnic vasoconstrictor agents,such as terlipressin,along with volume expansion,and early placement of transjugular intrahepatic portosystemic shunt(TIPS)may be effective in improving renal function in HRS.Continuous renal replacement therapy(CRRT)and molecular absorbent recirculating system(MARS)in selected patients may be life saving while awaiting liver transplantation.展开更多
AIM To assess the practice of caring for acute liver failure(ALF) patients in varying geographic locations and medical centers.METHODS Members of the European Acute Liver Failure Consortium completed an 88-item questi...AIM To assess the practice of caring for acute liver failure(ALF) patients in varying geographic locations and medical centers.METHODS Members of the European Acute Liver Failure Consortium completed an 88-item questionnaire detailing management of ALF. Responses from 22 transplantation centers in 11 countries were analyzed,treating between 300 and 500 ALF cases and performing over 100 liver transplants(LT) for ALF annually. The questions pertained to details of the institution and their clinical activity,standards of care,referral and admission,wardbased care versus intensive care unit(ICU) as well as questions regarding liver transplantation- including criteria,limitations,and perceived performance. Clinical data was also collected from 13 centres over a 3 mo period. RESULTS The interval between referral and admission of ALF patients to specialized units was usually less than 24 h and once admitted,treatment was provided by a multidisciplinary team. Principles of care of patients with ALF were similar among centers,particularly in relation to recognition of severity and care of the more critically ill. Centers exhibited similarities in thresholds for ICU admission and management of severe hepatic encephalopathy. Over 80% of centers administered n-acetyl-cysteine to ICU patients for non-paracetamolrelated ALF. There was significant divergence in the use of prophylactic antibiotics and anti-fungals,lactulose,nutritional support and imaging investigations in admitted patients and in the monitoring and treatment of intra-cranial pressure(ICP). ICP monitoring was employed in 12 centers,with the most common indications being papilledema and renal failure. Most patients listed for transplantation underwent surgery within an average waiting time of 1-2 d. Over a period of 3 mo clinical data from 85 ALF patients was collected. Overall patient survival at 90-d was 76%. Thirty six percent of patients underwent emergency LT,with a 90% post transplant survival to hospital discharge,42% survived with medical management alone. CONCLUSION Alongside similarities in principles of care of ALF patients,major areas of divergence were present in key areas of diagnosis,monitoring,treatment and decision to transplant.展开更多
文摘Renal dysfunction is common in liver diseases,either as part of multiorgan involvement in acute illness or secondary to advanced liver disease.The presence of renal impairment in both groups is a poor prognostic indicator.Renal failure is often multifactorial and can present as pre-renal or intrinsic renal dysfunction.Obstructive or post renal dysfunction only rarely complicates liver disease.Hepatorenal syndrome(HRS)is a unique form of renal failure associated with advanced liver disease or cirrhosis,and is characterized by functional renal impairment without significant changes in renal histology.Irrespective of the type of renal failure,renal hypoperfusion is the central pathogenetic mechanism,due either to reduced perfusion pressure or increased renal vascular resistance.Volume expansion,avoidance of precipitating factors and treatment of underlying liver disease constitute the mainstay of therapy to prevent and reverse renal impairment.Splanchnic vasoconstrictor agents,such as terlipressin,along with volume expansion,and early placement of transjugular intrahepatic portosystemic shunt(TIPS)may be effective in improving renal function in HRS.Continuous renal replacement therapy(CRRT)and molecular absorbent recirculating system(MARS)in selected patients may be life saving while awaiting liver transplantation.
文摘AIM To assess the practice of caring for acute liver failure(ALF) patients in varying geographic locations and medical centers.METHODS Members of the European Acute Liver Failure Consortium completed an 88-item questionnaire detailing management of ALF. Responses from 22 transplantation centers in 11 countries were analyzed,treating between 300 and 500 ALF cases and performing over 100 liver transplants(LT) for ALF annually. The questions pertained to details of the institution and their clinical activity,standards of care,referral and admission,wardbased care versus intensive care unit(ICU) as well as questions regarding liver transplantation- including criteria,limitations,and perceived performance. Clinical data was also collected from 13 centres over a 3 mo period. RESULTS The interval between referral and admission of ALF patients to specialized units was usually less than 24 h and once admitted,treatment was provided by a multidisciplinary team. Principles of care of patients with ALF were similar among centers,particularly in relation to recognition of severity and care of the more critically ill. Centers exhibited similarities in thresholds for ICU admission and management of severe hepatic encephalopathy. Over 80% of centers administered n-acetyl-cysteine to ICU patients for non-paracetamolrelated ALF. There was significant divergence in the use of prophylactic antibiotics and anti-fungals,lactulose,nutritional support and imaging investigations in admitted patients and in the monitoring and treatment of intra-cranial pressure(ICP). ICP monitoring was employed in 12 centers,with the most common indications being papilledema and renal failure. Most patients listed for transplantation underwent surgery within an average waiting time of 1-2 d. Over a period of 3 mo clinical data from 85 ALF patients was collected. Overall patient survival at 90-d was 76%. Thirty six percent of patients underwent emergency LT,with a 90% post transplant survival to hospital discharge,42% survived with medical management alone. CONCLUSION Alongside similarities in principles of care of ALF patients,major areas of divergence were present in key areas of diagnosis,monitoring,treatment and decision to transplant.
