SINDROMUL HEPATORENAL

Question 1

CADRU NOSOLOGIC

Answer 1

SRH = insuficienta renala functionala, potential reversibila
- apare la pacientii cu afectiuni hepatice severe
- in absenta unei patologii renale identificabile
- strctura histologica renala – normala

Transpantul hepatic – singura metoda eficienta de tratament

La 4% - din pacientii internati cu ciroza hepatica decompensata

Question 2

FACTORI PRECIPITANTI

Answer 2

Infectii bacteriene – PBS determina SHR in 20-30% din cazuri
- insuf renala data de disfunctia circulatorie indusa de citokine

-Paracenteze voluminoase, fara suplimentare de Albumina
-Hemoragii digestive
-Hepatita acuta alcoolica

factorii precipitanti sunt prezenti sunt responsbili de aparitia SHR tip1
❖SHR tip 2 - nu se identifica f precipitanti (inrautatirea bolii hepatice si
insuficienta mec compensatorii)

Question 3

DIAGNOSTIC

Answer 3

1. DIAGNOSTICUL INSUFICIENTEI RENALE
   - creatinina serica >1,5mg%
   - clearence creatininic <60ml/24 h
2. DIFERENTIREA DE ALTE CAUZE CARE POT EVOLUA CU INSUFICIENTA RENALA

Question 4

DIFERENTIREA DE ALTE CAUZE CARE POT EVOLUA CU INSUFICIENTA
RENALA

Answer 4

• necroza tubulara acuta (soc hemoragic sau infectios)
• insuficienta renala acuta de cauza prerenala (diuretice, HDS, paracenteze excesive)
• nefrotoxicitatea medicamentosa
• boli simultane hepatice si renale: glomerulonefrite crioglobulinemice
• infectii de tract urinar
• uropatii obstructive

Question 5

Criterii majore

Answer 5

✓Hepatopatie cronica sau acuta cu insuficienta hepatica avansata si HTP
✓Reducerea RFG: cl cr <40ml/24h, creatinina serica >1,5mg%
✓Absenta soc, sepsa, depletie volemica, medicamente
✓Neameliorarea functiei renale dupa sistarea diureticelor si reumplere volemica
✓Proteinurie< 500mg/zi
✓Ecografie: nu uropatie obstructiva, afectare parenchim

Question 6

Criterii aditionale

Answer 6

✓Volum urinar < 500ml/zi
✓Na urinar <10mEq/24h
✓Osmolaritate urinara > plasmatica
✓Hematurie <50hematii/camp
✓Natremie <130mEq//l

Question 7

PROFILAXIE

Answer 7

✓ Profilaxia infectiilor bacteriene
✓ Albumina la pac cu PBS sau dupa paracenteze voluminoase
✓ Tratament cu Pentoxifilin – hepatita alcoolica
✓ Utilizarea rationala a diureticelor
✓ Evitarea medicamentelor nefrotoxice: aminoglicozide AINS, sartani, IEC

Question 8

TRATAMENT

Answer 8

✓ FARMACOLOGIC
✓ TIPS
✓ SUPORTUL RENAL - HEMODIALIZA INTERMITENTA
- HEMOFILTRATEA CONTINUA
- MARS
✓ TRANSPLANT HEPATIC - tratament de electie
- preferabil inainte de aparitia SHR

Question 9

TRATAMENTE FARMACOLOGIC

Answer 9

Scheme terapeutice: Terlipresina+albumina
Octreodide+midodrine+albumina