肾功能障碍和肝硬化。
Renal dysfunction and cirrhosis.
机构信息
aHepatology & Liver Intensive Care, Hospital Beaujon, Clichy, University Paris Diderot, Paris, France bDivisions of Critical Care Medicine and Hepatology, University of Kansas Medical Center, Kansas City, Kansas cDivision of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, California, USA.
出版信息
Curr Opin Crit Care. 2017 Dec;23(6):457-462. doi: 10.1097/MCC.0000000000000457.
PURPOSE OF REVIEW
Hepatorenal syndrome (HRS) does not represent the predominant phenotype of acute kidney injury (AKI) in cirrhosis. Early recognition of HRS helps initiate appropriate therapy. The aims of this review are to present redefinition of AKI, to list new biomarkers, to report recent data on vasopressors in HRS and to propose criteria for simultaneous liver and kidney transplantation (SLKT).
RECENT FINDINGS
Urine output, which was not part of the definition of AKI might be reconsidered as it has an independent prognostic value. Biomarkers (NGAL and IL-18) could help identify ATN. However, cut-off values have to be clarified. Vasopressors with albumin represent first option in HRS. Continuous infusion of terlipressin has a better safety profile than intravenous boluses. SLKT should be considered whenever native kidney recovery is unlikely [i.e. prolonged renal replacement therapy (RRT) and/or GFR less than 25 ml/min for 6 weeks prior to transplantation].
SUMMARY
New definitions and recent biomarkers may help differentiate HRS from ATN at an earlier stage. Urine output should be reconsidered in the definitions. Even in patients who are not candidates for transplantation, a short trial of RRT is justified whenever needed. SLKT should be considered whenever posttransplant renal recovery is unlikely.
目的综述
肝肾综合征（HRS）并不代表肝硬化时急性肾损伤（AKI）的主要表现形式。早期识别 HRS 有助于启动适当的治疗。本文旨在介绍 AKI 的重新定义，列出新的生物标志物，报告 HRS 中血管加压素的最新数据，并提出同时进行肝和肾移植（SLKT）的标准。
最近的发现
尿输出量（AKI 定义中未包含的指标）可能需要重新考虑，因为它具有独立的预后价值。生物标志物（NGAL 和 IL-18）可帮助识别急性肾小管坏死（ATN）。但是，需要明确截断值。白蛋白结合的血管加压素是 HRS 的首选药物。与静脉推注相比，特利加压素的持续输注具有更好的安全性。如果预计患者的原生肾脏无法恢复（例如，在移植前 6 周内需要进行长时间的肾脏替代治疗（RRT）和/或肾小球滤过率（GFR）<25ml/min），应考虑进行 SLKT。
总结
新的定义和最近的生物标志物可能有助于更早地区分 HRS 和 ATN。应重新考虑在定义中纳入尿输出量。即使患者不符合移植条件，在需要时，也应进行短期的 RRT 试验。如果预计患者移植后的肾脏恢复可能性较小，则应考虑进行 SLKT。
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