Barbano Biagio, Sardo Liborio, Gigante Antonietta, Gasperini Maria Ludovica, Liberatori Marta, Giraldi Gianluca Di Lazzaro, Lacanna Antonio, Amoroso Antonio, Cianci Rosario
Department of Nephrology, "Sapienza", University of Rome, Viale dell'Universita, 37, 00185, Rome, Italy.
Curr Vasc Pharmacol. 2014 Jan;12(1):125-35. doi: 10.2174/157016111201140327163930.
Advanced cirrhosis is frequently associated with renal dysfunction. Hepatorenal syndrome (HRS) is characterized by the occurrence of kidney injury in cirrhotic patients in the absence of other identifiable causes. HRS is classified in 2 different types. Type 1 is characterized by acute renal failure and rapid functional deterioration of other organs, usually related to a precipitating event. Type 2 is characterized by slowly progressive renal failure and refractory ascites. Advanced liver disease induces the progression of hemodynamic alterations such as arterial vasodilation of splanchnic circulation and impairment of cardiac function. The resulting ineffective circulating blood volume promotes the activation of both the renin-angiotensin-aldosterone and sympathetic nervous system, by an increase of antidiuretic hormone activity, in an attempt to restore volemia. Despite fluid retention, ascites and dilutional hyponatremia, renal function is often initially preserved by renal production of vasodilators. However, further insults can lead to an imbalance between systemic vasoconstriction and local renal vasodilation, resulting in progressive renal failure. Over the last decade, clinical strategies to prevent HRS have been improved by a better understanding of the natural history of renal failure in cirrhosis, resulting in a reduction of HRS prevalence in cirrhotic patients. Vasoconstrictor drugs may improve renal function, but the effect on mortality has not yet been established. Vaptans, nonpeptide vasopressin receptor antagonists, may also reduce hyponatraemia and ascites, even if the clinical effects in HRS remain unknown. This review updates the pathophysiology, diagnosis and management of HRS.
晚期肝硬化常伴有肾功能不全。肝肾综合征（HRS）的特征是肝硬化患者在无其他可识别病因的情况下发生肾损伤。HRS分为2种不同类型。1型以急性肾衰竭和其他器官功能迅速恶化为特征，通常与诱发事件有关。2型以缓慢进展的肾衰竭和顽固性腹水为特征。晚期肝病会促使血流动力学改变进展，如内脏循环动脉血管舒张和心功能受损。由此导致的有效循环血容量不足会通过增加抗利尿激素活性来促进肾素-血管紧张素-醛固酮系统和交感神经系统的激活，试图恢复血容量。尽管存在液体潴留、腹水和稀释性低钠血症，但肾功能最初常因肾脏产生血管舒张剂而得以保留。然而，进一步的损伤可导致全身血管收缩与局部肾血管舒张之间失衡，从而导致进行性肾衰竭。在过去十年中，通过对肝硬化肾衰竭自然史的更好理解，预防HRS的临床策略得到了改进，导致肝硬化患者中HRS的患病率降低。血管收缩剂药物可能改善肾功能，但对死亡率的影响尚未确定。血管加压素受体拮抗剂（非肽类）也可能减轻低钠血症和腹水，尽管其对HRS的临床效果尚不清楚。本综述更新了HRS的病理生理学、诊断和管理。
