Hepatorenal syndrome often abbreviated HRS is a life-threatening medical condition that consists of rapid deterioration in kidney function in individuals with cirrhosis or fulminant liver failure. HRS is usually fatal unless a liver transplant is performed, although various treatments, such as dialysis , can prevent advancement of the condition. HRS can affect individuals with cirrhosis, severe alcoholic hepatitis , or liver failure, and usually occurs when liver function deteriorates rapidly because of a sudden insult such as an infection, bleeding in the gastrointestinal tract , or overuse of diuretic medications. Deteriorating liver function is believed to cause changes in the circulation that supplies the intestines , altering blood flow and blood vessel tone in the kidneys. The kidney failure of HRS is a consequence of these changes in blood flow, rather than direct damage to the kidney.
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Hepatorenal syndrome, septic shock and renal failure as mortality predictors in patients with spontaneous bacterial peritonites. Background and aims: Spontaneous bacterial peritonitis SBP is a common complication of cirrhosis. Identification of poor prognosis predictors is essential in disease approach. Methods: Medical records from patients admitted at our institution between January and December with spontaneous bacterial peritonitis were retrospectively reviewed.
Criteria assessed were age, sex, presenting symptoms, risk factors, ascitic fluid characteristics, evolution during hospitalization, prophylaxis at discharge and re-admission. Results: 42 34 male, 8 female patients were included in the study.
Mean age was Abdominal pain was the most common presenting symptom In the remaining, Escherichia coli Average length of hospitalization was Mortality rate was Of the Conclusion: The mortality is elevated, with hepatorenal syndrome and septic shock being potential predictors of mortality.
Ceftriaxone fails in a high percentage of SBP episodes and may not be the most appropriate first-line treatment.
Resultados: Foram incluidos 42 doentes no estudo 34 do sexo masculino e 8 do sexo feminino. O ceftriaxone pode nao ser o antibiotico empirico de primeira linha mais adequado, tendo em conta a falencia terapeutica numa percentagem elevada de doentes.
Spontaneous bacterial peritonitis SBP is a common and severe complication in patients with advanced cirrhosis. It is defined as an ascitic fluid infection without an evidente intra-abdominal cause. The diagnosis of SBP is established with a diagnostic paracentesis. Their clinical presentation is similar to that of patients with culture-positive SBP and should be given the same treatment. The clinical presentation in SBP is non-specific. Patients, particularly outpatients, may be asymptomatic.
Other signs and symptoms associated include fever, abdominal pain, chills, nausea or vomiting, ileus, diarrhea, mental status changes and renal impairment.
Antibiotics should be started at diagnosis and adjusted, if necessary, according with the ascitic fluid cultural results.
A second paracentesis, 48 h after the beginning of antibiotic therapy, should be made to assess a decline in the neutrophil count, when no clinical improvement occurs or when the initial ascitic fluid analysis revealed atypical findings. Certain subgroups of patients with cirrhosis and ascites have a higher risk of developing SBP and should be on a prophylaxis antibiotic regimen.
The use of prophylactic antibiotics is approved in patients with acute gastrointestinal hemorrhage, patients with low total protein concentration in ascitic fluid and no prior history of SBP and patients with a previous history of SBP. Approximately half of all deaths in patients with SBP occur after the resolution of the infection and are usually the result of gastrointestinal hemorrhage, liver or renal failure.
The presence of renal failure is the strongest independente prognostic indicator, but the presence of peripheral leukocytosis, advanced age, higher Child-Pugh score and ileus have also shown to predict inpatient mortality. The existence of a positive ascitic fluid culture or bacteremia does not seem to influence prognosis.
The aim of this study was to characterize a consecutive series of patients with SBP diagnosis, regarding risk factors, complications during hospitalization and their influence in prognostic. Medical records from patients admitted between January and December with the diagnosis of SBP either at admission or during hospitalization were reviewed. The criteria assessed were:. Patients without cirrhosis and presenting with ascites were excluded. When the end point evaluated was death, the period ranging from date of hospitalization admission to date of death was considered the survival period.
Data were analyzed using a statistical software program SPSS The chi-square test was used, when appropriate, to determine the differences in proportions. The independent role of factors selected by univariate analysis was further assessed by stepwise regression analysis. Kaplan-Meier methodology was performed to analyze the survival of patients within the different groups. The log rank test was used to evaluate the statistical differences between survival curves.
The Cox regression analysis was performed to analyze the Hazard risk. The statistical significance was established at a P value of less than 0. SBP was diagnosed at hospital admission in 35 The mean age at admission was Abdominal pain, present in 25 Three patients 7.
Seventeen patients At hospital admission 12 patients Total serum bilirubin, plasma creatinine, plasma sodium and the presence of esophageal varices did not show a statistically significant association with a higher mortality risk. Regarding the first paracentesis done during hospitalization, Twenty three Thirty one Of those on Ceftriaxone, 10 The average length of hospitalization was Of the 30 SBP is a common complication in patients with cirrhosisrelated ascites.
In our series, only three of the patients had previous SBP diagnosis, with one of them being on a prophylaxis antibiotic regimen. For this reason, it was not possible to assess the effect of prophylaxis in survival. Most patients were in an advanced phase of the disease Child-Pugh C.
Abdominal pain was the most frequente symptom at admission, although in other studies published fever was the most common symptom reported. Total serum bilirubin concentration, plasma creatinine and plasma sodium levels did not alter the risk of death in a statistically significant way. In this study we retrospectivelly examined the presence of complications in association with bilirubin, creatinine and sodium levels. Further studies must include the assessment of the effect of these variables in the risk of developing complications.
The presence of hepatorenal syndrome and septic shock influenced the outcome, with those patients with hepatorenal syndrome having a twenty-nine times higher risk of death and those with septic shock having a nine times higher risk. Renal failure was also suggestively associated with death.
We might say that the presence of hepatorenal syndrome and septic shock are potential predictors of mortality risk. This is further supported by the findings of Angeloni et al. These results should promote further investigation aimed at identifying different treatment approaches.
Despite the latest guidelines that support the use of antibiotic prophylaxis in all patients with SBP after hospital discharge, 20 in our study only Nevertheless, re-admissions in this sub-group were not statistically significantly diferente from those not on prophylaxis.
It is possible that no significance was found owing to a lack of statistical power based on the small number of patients included in the study. It was not possible to evaluate in this study if SBP patients on proton pump inhibitors had a higher rate of SBP than those who were not. In further studies this should be assessed. The fact that the study was retrospective, made it more difficult to analyze certain variables, as data was missing in some patients files.
Patient search and selection was limited to patients with SBP diagnosis, based on the CDI classification, by the time of discharge or death. There might have been more patients in whom this diagnosis was not done or who were not correctly codified.
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2012, Número 05
Instrucciones a los autores. Instrucciones a los evaluadores. Instrucciones a los editores asociados. Referencias 1. A liver —Kidney sindrome. Clinical,pathological and experimental studies. Surg Gynecol Obst 1.