Keller F, Heinze H, Jochimsen F, Passfall J, Schuppan D, Büttner P
Department of Internal Medicine and Nephrology, Steglitz Medical Center Free University of Berlin, Germany.
Ren Fail. 1995 Mar;17(2):135-46. doi: 10.3109/08860229509026250.
The prognosis of acute renal failure in patients with preexisting liver decompensation is poor, and hemodialysis is considered futile, especially for hepatorenal syndrome (HRS). Since we observed a more favorable outcome in some patients, we retrospectively evaluated 107 patients with decompensated liver disease and acute renal failure (serum creatinine > 200 mumol/L) treated at the medical department of a university hospital in a 10-year period (1980-1990). HRS in the strict sense (urine-Na < 20 mmol/L while on furosemide) was diagnosed in 26 of 107 patients (24%). Renal function remained compensated in 25 patients, while 82 patients fulfilled the criteria for dialysis treatment (creatinine > 500 mumol/L and/or diuresis < 500 mL/day). In contrast to the current doctrine, 38 of the 82 patients were given hemodialysis (46%). Using the Cox proportional hazard model, the relative risk (presence vs. absence of a risk factor) of dying was increased 8.2-fold (3.9-17.2) in patients with thrombocytopenia < 100/nL, 3.9-fold (1.4-11.3) in those with hepatic encephalopathy and prothrombin time < 30%, 2.8-fold (1.6-4.8) in patients with malignoma, and 2.7-fold (1.5-4.8) in patients not submitted to dialysis despite its indication. In the CART statistics (classification and regression trees), the 33 patients with the poorest outcome were characterized exclusively by thrombocytopenia < 100/nL. HRS in the strict sense was not an independent risk factor. The CART group of 43 patients with favorable prognosis (compensated renal failure or treatment by hemodialysis, absent malignancy) had a 1-year survival rate of 38%. We conclude that thrombocytopenia, encephalopathy, and malignoma, but not HRS per se, are fatal signs that make hemodialysis futile in patients with acute renal failure and decompensated liver disease.
已有肝脏失代偿的患者发生急性肾衰竭时预后较差，血液透析被认为是无效的，尤其是对于肝肾综合征（HRS）。由于我们观察到部分患者有较好的预后，因此我们回顾性评估了一所大学医院内科在10年期间（1980 - 1990年）收治的107例伴有急性肾衰竭（血清肌酐>200μmol/L）的失代偿性肝病患者。107例患者中有26例（24%）被诊断为严格意义上的HRS（使用速尿时尿钠<20mmol/L）。25例患者的肾功能保持代偿，而82例患者符合透析治疗标准（肌酐>500μmol/L和/或尿量<500ml/天）。与当前学说相反，82例患者中有38例（46%）接受了血液透析。使用Cox比例风险模型，血小板减少<100/nL的患者死亡的相对风险（存在与不存在风险因素相比）增加8.2倍（3.9 - 17.2），有肝性脑病且凝血酶原时间<30%的患者增加3.9倍（1.4 - 11.3），患有恶性肿瘤的患者增加2.8倍（1.6 - 4.8），尽管有透析指征但未接受透析的患者增加2.7倍（1.5 - 4.8）。在CART统计（分类与回归树）中，预后最差的33例患者仅以血小板减少<100/nL为特征。严格意义上的HRS不是独立的风险因素。CART组中43例预后良好的患者（肾功能代偿或接受血液透析治疗，无恶性肿瘤）的1年生存率为38%。我们得出结论，血小板减少、脑病和恶性肿瘤，而非HRS本身，是导致伴有急性肾衰竭和失代偿性肝病的患者进行血液透析无效的致命征象。
