【正文】 reased survival compared with ascitic patients without renal failure (median survival approximately 6 months),第五十五頁，共六十九頁。,肝腎綜合征對肝移植結(jié)局(ji233。j)的影響,HRS, hepatorenal syndrome Gonwa et al. Transplantation 1995。 59: 361–365,HRS患者(hu224。nzhě)肝移植后結(jié)局更差!,第五十六頁，共六十九頁。,肝腎綜合征治療史對移植后結(jié)局(ji233。j)的影響,前瞻性研究比較(bǐji224。o)有HRS治療的患者與無HRS患者肝移植后結(jié)局,移植前經(jīng)歷HRS治療的患者與無HRS患者，在肝移植后結(jié)局無明顯(m237。ngxiǎn)差異！,第五十七頁，共六十九頁。,Initial management of hepatorenal syndrome: a checklist,Admission to hospital (general ward/intensive care unit*) Central line placement is helpful but not mandatory Complete blood tests Abdominal ultrasound to examine the liver and kidneys 24hour urine collection urine Na+/K+ urine volume urine sediment/protein Diagnostic paracentesis to exclude ongoing infection albumin, cell count, fluid culture in blood culture bottles Plasma expansion with albumin to rule out prerenal failure Nutritionist consultation to manage malnutrition Evaluation for orthotopic liver transplantation,Adapted from Cardenas et al. Clin Liver Dis 2006: 10: 371–385,第五十八頁，共六十九頁。,Treatment of HRS with albumin and terlipressin,Mart237。nLlah237。 et al. Gastroenterology 2008。 134: 1352–1359,第五十九頁，共六十九頁。,Results: albumin in association with terlipressin improves renal function in patients with HRS,Mart237。nLlah237。 et al. Gastroenterology 2008。 134: 1352–1359,白蛋白+特利加壓素治療(zh236。li225。o)HRS，腎功能改善顯著高于單用白蛋白組！,p=0.017,10/23,2/23,第六十頁，共六十九頁。,Treatment of HRS with terlipressin and albumin,GFR, glomerular filtration rate。 MAP, mean arterial pressure。 PRA, plasma renin activity Ortega et al. Hepatology 2002。 36: 941–948,*p0.05 with respect to baseline,白蛋白是HRS治療有效(yǒuxi224。o)的獨(dú)立預(yù)測因素！,第六十一頁，共六十九頁。,Treatment of HRS with albumin and terlipressin: survival,Ortega et al. Hepatology 2002。 36: 941–948,HRS, hepatorenal syndrome,白蛋白的應(yīng)用是生存的獨(dú)立(dl236。)預(yù)測因素！,第六十二頁，共六十九頁。,European guidelines for the management of hepatorenal syndrome,EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010。 53: 397–417,Monitor carefully, screen for sepsis,Consider LVP with albumin if indicated,Suspend diuretics during diagnosis and evaluation,Albumin with terlipressin is firstline drug therapy,Liver transplantation is the optimal treatment HRS should be treated before the procedure to improve outcomes,第六十三頁，共六十九頁。,小 結(jié),HRS預(yù)后極差。 研究表明，白蛋白與血管加壓素聯(lián)合應(yīng)用(y236。ngy242。ng)可顯著改善HRS的治療效果。 歐洲指南推薦白蛋白+血管活性藥作為HRS的一線治療藥物。,第六十四頁，共六十九頁。,Conclusions 總 結(jié),第六十五頁，共六十九頁。,Hepatic indications for albumin,PPCD, postparacentesis circulatory dysfunction。 LVP, largevolume paracentesis。 SBP, spontaneous bacterial peritonitis。 HRS, hepatorenal syndrome,There are three main indications for volume replacement with albumin in liver disease prevention of PPCD following LVP prevention of renal failure in patients with SBP treatment of HRS (as an adjunct to vasoconstrictors),Supported by several clinical studies and metaanalyses,Advocated by European and American guidelines,第六十六頁，共六十九頁。,Increased risk,Complication,Treatment,Outcome,Increased risk,*Albumin recommended in EASL4 and AASLD5 guidelines LVP, largevolume paracentesis。 PPCD, postparacentesis circulatory dysfunction 1Bernardi et al. Hepatology 2012。 55: 1172–1181。 2Ortega et al. Hepatology 2002。 36: 941–948。 3Sort et al. N Engl J Med 1999。 341: 403–409。 4EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010。 53: 397–417。 5Runyon et al. Hepatology 2009。 49: 2087–2107,Hepatic indications for albumin (cont’d),↓ PPCD1 ↓ hyponatraemia1 ↓ Mortality1,↓ Renal impairment2 ↓ Mortality2,↓ Renal impairment3 ↓ Mortality3,Large/grade 3 ascites,Hepatorenal syndrome Type 1,Spontaneous bacterial peritonitis,Disease,CIRRHOSIS WITH ASCITES,第六十七頁，共六十九頁。,謝 謝,第六十八頁，共六十九頁。,內(nèi)容(n232。ir243。ng)總結(jié),概 要。大面積燒傷（補(bǔ)晶體液、補(bǔ)蛋白、維持血容量）。極少發(fā)生低血壓、呼吸困難(hū xī k249。n n225。n)、甚至休克等嚴(yán)重過敏性變態(tài)反應(yīng)。ChildPughTurcotte1。RAA, reninaldosteroneangiotensin。N.S.。謝,第六十九頁，共六十