Cai Cindy X, Maddukuri Geetha, Jaipaul Navin, Zhang Zhiwei
Division of Gastroenterology, Department of Medicine, VA Loma Linda Healthcare System and Loma Linda University, Loma Linda, CA, 92357, USA.
Dig Dis Sci. 2015 May;60(5):1474-81. doi: 10.1007/s10620-014-3483-x. Epub 2014 Dec 23.
The principle of treating-to-target has been successfully applied to many diseases with significant improvement in patient care and as a useful guidance for healthcare providers. Appreciation of the central role for arterial vasodilatation in the pathogenesis of hepatorenal syndrome (HRS) has led to routine use of vasoconstrictors in combination with albumin in patients with HRS. An appropriate target to guide such therapy, however, has not yet been established.
The purpose of the current study was to identify a suitable target that can predict clinical outcome and guide the medical management of type 1 HRS, a condition associated with very poor prognosis.
A total of 85 patients with type 1 HRS who received a combination therapy of vasoconstrictors and albumin were enrolled. A potential therapeutic target was identified by univariate and multivariate logistic regression analyses. The treat-to-target concept to guide the management of HRS was then tested via a retrospective cohort study.
A change in mean arterial pressure (MAP) during treatment was identified as a sole independent predictor for patient survival. Compared with mild or no increase in MAP, achievement in a marked increase in MAP of more than 10 mmHg in these patients was associated with better overall survival and transplant-free survival. Increased MAP to higher than 15 mmHg did not result in further improvement in clinical outcome.
A treat-to-target concept by the use of a specific goal of MAP is feasible and may potentially guide the medical management of type 1 HRS.
治疗达标原则已成功应用于多种疾病，显著改善了患者护理，并为医疗服务提供者提供了有用的指导。鉴于动脉血管舒张在肝肾综合征（HRS）发病机制中的核心作用，血管收缩剂与白蛋白联合应用已成为HRS患者的常规治疗方法。然而，尚未确立指导此类治疗的合适目标。
本研究旨在确定一个合适的目标，以预测1型HRS的临床结局并指导其医疗管理，1型HRS的预后非常差。
共纳入85例接受血管收缩剂与白蛋白联合治疗的1型HRS患者。通过单因素和多因素逻辑回归分析确定潜在的治疗靶点。然后通过回顾性队列研究验证治疗达标概念对HRS管理的指导作用。
治疗期间平均动脉压（MAP）的变化被确定为患者生存的唯一独立预测因素。与MAP轻度升高或无升高相比，这些患者MAP显著升高超过10 mmHg与更好的总生存率和无移植生存率相关。MAP升高至高于15 mmHg并未导致临床结局进一步改善。
以MAP的特定目标为导向的治疗达标概念是可行的，可能为1型HRS的医疗管理提供指导。
