Divisions of Nephrology and Critical Care Medicine, Department of Internal Medicine, UT Southwestern, Dallas, Texas, USA.
Curr Opin Nephrol Hypertens. 2018 Jul;27(4):289-297. doi: 10.1097/MNH.0000000000000425.
Acute liver failure (ALF) is a severe and complex illness and one of the most daunting conditions managed in the ICU. Because the renal care is intertwined with multiple disciplines, the aim of this review is to examine the multifactorial pathogenesis of cerebral edema in ALF, covering basic established facts as well as recent advances in our understanding of this condition.
Acetaminophen remains the most common cause of ALF in the United States and many European countries. The incidence of cerebral edema continues to decline owing to earlier detection and improved management. The pathogenesis of cerebral edema has shifted from a unifactorial hypothesis involving the failed liver to a multifactorial cause. Recent evidence focuses on the role of liver-induced systemic inflammation and its implication in increasing the permeability of the blood-brain barrier. The role of brain aquaporin-4 in mediating water entry into the brain is further clarified. Controversial data regarding the effect of acute kidney injury on the brain emerged. Hyponatremia has been shown to worsen the outcome in acute-on-chronic liver failure patients thus validating findings in animal models. New evidence shed the light on the changes in serum osmolality and potential tissue hypoxia during continuous renal replacement therapy and points to the risks associated with such therapy.
ALF is a severe systemic illness that is potentially reversible. Understanding the interaction between the multiple failed organs will help the nephrologist provide well tolerated and efficient care.
急性肝衰竭（ALF）是一种严重且复杂的疾病，也是重症监护病房（ICU）中最难处理的病症之一。由于肾脏的护理与多个学科交织在一起，因此本篇综述的目的是检查 ALF 中脑水肿的多因素发病机制，涵盖基本确立的事实以及我们对该病症理解的最新进展。
在美国和许多欧洲国家，对乙酰氨基酚仍然是 ALF 的最常见原因。由于早期发现和改善管理，脑水肿的发生率持续下降。脑水肿的发病机制已从涉及肝功能衰竭的单因素假说转变为多因素病因。最近的证据集中在肝诱导的全身炎症在增加血脑屏障通透性方面的作用。脑水通道蛋白-4在介导水进入大脑中的作用进一步得到阐明。关于急性肾损伤对大脑的影响存在争议性数据。低钠血症已被证明会使急性肝性慢性肝衰竭患者的预后恶化，从而验证了动物模型中的发现。新的证据揭示了连续性肾脏替代治疗期间血清渗透压和潜在组织缺氧的变化，并指出了与这种治疗相关的风险。
ALF 是一种严重的全身性疾病，具有潜在的可逆性。了解多个衰竭器官之间的相互作用将有助于肾脏病学家提供耐受良好且有效的护理。
