Mindikoglu Ayse L, Dowling Thomas C, Wong-You-Cheong Jade J, Christenson Robert H, Magder Laurence S, Hutson William R, Seliger Stephen L, Weir Matthew R
Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Md., USA.
Am J Nephrol. 2014;39(6):543-52. doi: 10.1159/000363584. Epub 2014 Jun 17.
Renal hemodynamic measurements are complicated to perform in patients with cirrhosis, yet they provide the best measure of risk to predict hepatorenal syndrome (HRS). Currently, there are no established biomarkers of altered renal hemodynamics in cirrhosis validated by measured renal hemodynamics.
In this pilot study, simultaneous measurements of glomerular filtration rate (GFR), renal plasma flow (RPF), renal resistive indices and biomarkers were performed to evaluate renal hemodynamic alterations in 10 patients with cirrhosis (3 patients without ascites, 5 with diuretic-sensitive and 2 diuretic-refractory ascites).
Patients with diuretic-refractory ascites had the lowest mean GFR (36.5 ml/min/1.73 m(2)) and RPF (133.6 ml/min/1.73 m(2)) when compared to those without ascites (GFR 82.9 ml/min/1.73 m(2), RPF 229.9 ml/min/1.73 m(2)) and with diuretic-sensitive ascites (GFR 82.3 ml/min/1.73 m(2), RPF 344.1 ml/min/1.73 m(2)). A higher mean filtration fraction (FF) (GFR/RPF 0.36) was noted among those without ascites compared to those with ascites. Higher FF in patients without ascites is most likely secondary to the vasoconstriction in the efferent glomerular arterioles (normal FF ~0.20). In general, renal resistive indices were inversely related to FF. While patients with ascites had lower FF and higher right kidney main and arcuate artery resistive indices, those without ascites had higher FF and lower right kidney main and arcuate artery resistive indices. While cystatin C and β2-microglobulin performed better compared to Cr in estimating RPF, β-trace protein, β2-microglobulin, and SDMA, and (SDMA+ADMA) performed better in estimating right kidney arcuate artery resistive index.
The results of this pilot study showed that identification of non-invasive biomarkers of reduced RPF and increased renal resistive indices can identify cirrhotics at risk for HRS at a stage more amenable to therapeutic intervention and reduce mortality from kidney failure in cirrhosis.
在肝硬化患者中进行肾血流动力学测量很复杂，但它们能提供预测肝肾综合征（HRS）风险的最佳指标。目前，尚无经测量的肾血流动力学验证的肝硬化患者肾血流动力学改变的既定生物标志物。
在这项初步研究中，对10例肝硬化患者（3例无腹水，5例利尿剂敏感型腹水，2例利尿剂抵抗型腹水）同时测量肾小球滤过率（GFR）、肾血浆流量（RPF）、肾阻力指数和生物标志物，以评估肾血流动力学改变。
与无腹水患者（GFR 82.9 ml/min/1.73 m²，RPF 229.9 ml/min/1.73 m²）和利尿剂敏感型腹水患者（GFR 82.3 ml/min/1.73 m²，RPF 344.1 ml/min/1.73 m²）相比，利尿剂抵抗型腹水患者的平均GFR（36.5 ml/min/1.73 m²）和RPF（133.6 ml/min/1.73 m²）最低。与有腹水患者相比，无腹水患者的平均滤过分数（FF）（GFR/RPF 0.36）更高。无腹水患者的FF较高很可能是由于肾小球出球小动脉血管收缩所致（正常FF约为0.20）。一般来说，肾阻力指数与FF呈负相关。有腹水患者的FF较低，右肾主动脉和弓状动脉阻力指数较高，而无腹水患者的FF较高，右肾主动脉和弓状动脉阻力指数较低。在估计RPF方面，胱抑素C和β2-微球蛋白比肌酐表现更好，而β-微量蛋白、β2-微球蛋白、SDMA以及（SDMA + ADMA）在估计右肾弓状动脉阻力指数方面表现更好。
这项初步研究结果表明，识别RPF降低和肾阻力指数升高的非侵入性生物标志物可以在更适合治疗干预的阶段识别出有HRS风险的肝硬化患者，并降低肝硬化患者肾衰竭的死亡率。
