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Diagnosis and treatment of acute renal failure in patients with cirrhosis. |
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Diagnosis and treatment of acute renal failure in patients with cirrhosis.
Best Pract Res Clin Gastroenterol. 2007;21(1):111-123.
Moreau R, Lebrec D.
INSERM,
U773, Centre de Recherche Biomedicale Bichat-Beaujon CRB3, and Service
d'Hepatologie, Hopital Beaujon, 92118 Clichy, France.
In
patients with cirrhosis, acute renal failure is due to prerenal failure
(a result of decreased renal perfusion) and tubular necrosis. There are
3 main causes of prerenal failure: 'true hypovolemia' (which
complicates hemorrhage, gastrointestinal or renal fluid losses),
sepsis, and type 1 hepatorenal syndrome (HRS).
Prerenal failure may
also be due to the administration of non-steroidal antiinflammatory
drugs, or intravascular radiocontrast agents. Prerenal failure is
reversible after restoration of renal blood flow. Treatments target the
cause of hypoperfusion, and fluid replacement is used to treat
'non-HRS' prerenal failure. In patients with type 1 HRS with very low
short-term survival rate, liver transplantation is the ideal treatment.
Systemic vasoconstrictor therapy with terlipressin (combined with
intravenous human albumin), noradrenaline (combined with albumin and
furosemide) or midodrine (combined with octreotide and albumin) may
improve renal function in patients with type 1 HRS waiting for liver
transplantation. MARS (for Molecular Adsorbent Recirculating System)
and the transjugular intrahepatic portosystemic shunt may also improve
renal function in these patients. In patients with cirrhosis, acute
tubular necrosis is mainly due to an ischemic insult to the renal
tubules. Studies are needed on the natural course and treatment (e.g.,
renal-replacement therapy) of acute tubular necrosis in patients with
cirrhosis.
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