肝肾综合症课件.ppt

肝肾综合征: 国际腹水协会诊断标准 血清肌酐133 μmol/L (1.5 mg/dl). 2. 停止使用利尿剂和使用白蛋白(1 g/kg/日， 最多 100 g/日).扩容治疗后2天，血清肌酐水平无改善( 1.5mg/dl) 3. 未出现休克，或近期使用过肾毒性药物 4. 无肾实质病变(蛋白尿500mg/日)，无微小血尿和/或超声波肾脏异常发现 Major differences Renal failure with ongoing bacterial infection, but in the absence of septic shock is considered HRS. Treatment can be started without waiting for resolution of infection. Plasma volume expansion should be performed with albumin rather than saline Minor diagnostic criteria were removed as they added little to the diagnosis of HRS. Initial management checklist for patients with HRS Admission to monitored care unit Central line placement is helpful but not mandatory Complete blood tests Exclude ongoing infection Abdominal ultrasound to examine the liver and kidneys 24 hr urine collection: Urine sodium Urine volume Urine sediment Diagnostic paracentesis Albumin, cell count , culture in blood culture bottles Plasma expansion with albumin to rule out prerenal renal failure Nutrition consultation Evaluation for orthotopic liver transplantation PREVENTION OF HRS Renal failure from SBP can be prevented with IV albumin: 1.5 gr/kg at diagnosis and 1gr/kg 48 hours later Norfloxacin 400mg/day (selected patients) Plasma expansion after therapeutic taps. Terlipressin Initial dose: 0.5 to 1 mg every 4 -6 hours Increase in a stepwise fashion to 1-2 mg every 4-6 hours every 3 days if a significant reduction in serum creatinine level ( 25% of the pre-treatment value or ≥ 1mg/dL) is not observed during a 3-day period. The recommended dose of albumin is 1 g/kg followed by 20-40 g/day. In most cases renal function starts to improve within 5 - 6 days. Side effects : approximately 10% (cramps, diarrhea, ischemic events). HRS improves in ~40-60% of patients Low recurrence upon discontinuation of therapy * . 肝肾综合症 HEPATORENAL SYNDROME HEPATORENAL SYNDROME 肝肾综合征 Renal abnormalities 肾脏异常 - Marked renal vasoconstriction 肾血管强烈收缩 - Marked reduction of GFR 肾小