Marik Paul E, Wood Kelly, Starzl Thomas E
Department of Critical Care Medicine, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, PA, USA.
Nephrol Dial Transplant. 2006 Feb;21(2):478-82. doi: 10.1093/ndt/gfi212. Epub 2005 Oct 25.
Hepato-renal syndrome (HRS) is a functional form of renal failure that occurs in patients with end-stage liver disease. Previously considered fatal without liver transplantation, treatment with vasoconstrictors and albumin has been demonstrated to improve renal function in patients with type 1 HRS. Liver transplantation is still considered the definitive treatment for HRS. However, the renal recovery rate and those factors that predict recovery post orthotopic liver transplantation have not been determined.
We reviewed the hospital course of 28 patients who met the International Ascites Club criteria for type I HRS and who underwent orthotopic liver transplant. The patients' demographic and pre- and post-operative laboratory data were recorded; patients were followed for 4 months post-transplantation or until death.
The MELD score of the patients was 30+/-6. The mean duration of HRS prior to liver transplantation was 37+/-27 days. HRS resolved in 16 patients (58%). The mean time to resolution of HRS was 21+/-27 days, with a range of 4-110 days. Eight (50%) patients in whom the HRS resolved were undergoing pre-transplantation dialysis. The age of the recipients (49+/-10 vs 56+/-12; P = 0.05), the total bilirubin level on post-operative day 7 (6.0+/-4.3 vs 10.1+/-5.9 mg/dl; P = 0.04), alcoholic liver disease and the requirement for post-transplant dialysis were predictors of resolution of HRS by univariate analysis. Only alcoholic liver disease and post-transplant dialysis were independent (negative) predictors of resolution of HRS. Seven of the 12 (58%) patients who developed chronic renal insufficiency remained dialysis dependent. The pre-operative serum creatinine was non-significantly higher in the non-resolvers who remained dialysis dependent compared to those who did not require long-term dialysis (3.0+/-1.0 vs 2.3+/-0.4 mg/dl; P = 0.1) Four patients died; in three of these patients the HRS had resolved prior to their death.
HRS is not always cured by orthotopic liver transplant. Pre-transplantation dialysis or a long waiting period should not preclude transplantation in patients with HRS. HRS may not resolve in patients with alcoholic liver disease. We were unable to accurately define that group of patients with HRS who required long-term dialysis and could theoretically benefit from combined liver-kidney transplantation.
肝肾综合征（HRS）是终末期肝病患者发生的一种功能性肾衰竭形式。以前认为未经肝移植则会致命，现已证明使用血管收缩剂和白蛋白治疗可改善1型HRS患者的肾功能。肝移植仍被视为HRS的确定性治疗方法。然而，肾脏恢复率以及预测原位肝移植后恢复的因素尚未确定。
我们回顾了28例符合国际腹水俱乐部1型HRS标准并接受原位肝移植患者的住院病程。记录患者的人口统计学资料以及术前和术后实验室数据；对患者进行移植后4个月的随访或直至死亡。
患者的终末期肝病模型（MELD）评分是30±6。肝移植前HRS的平均持续时间为37±27天。16例患者（58%）的HRS得到缓解。HRS缓解的平均时间为21±27天，范围为4 - 110天。8例（50%）HRS得到缓解的患者在移植前接受透析。单因素分析显示，受者年龄（49±10岁对56±12岁；P = 0.05）、术后第7天的总胆红素水平（6.0±4.3对10.1±5.9mg/dl；P = 0.04）、酒精性肝病以及移植后透析需求是HRS缓解的预测因素。只有酒精性肝病和移植后透析是HRS缓解的独立（阴性）预测因素。12例发生慢性肾功能不全的患者中有7例（58%）仍依赖透析。与那些不需要长期透析的患者相比，仍依赖透析的未缓解患者术前血清肌酐略高（3.0±1.0对2.3±0.4mg/dl；P = 0.1）。4例患者死亡；其中3例患者在死亡前HRS已缓解。
原位肝移植并非总能治愈HRS。移植前透析或长时间等待不应排除HRS患者进行移植。酒精性肝病患者的HRS可能无法缓解。我们无法准确界定那组需要长期透析且理论上可从肝肾联合移植中获益的HRS患者。
