Hepatorenal Syndrome is one of major complication of Liver Cirhosis.......Early detection & Accurate Treatment....26/6/2016 at Kafrelsheik University ( Resident Lectures).
A simple description of a less understood topic in Intensive Care Medicine. Aim to make understanding and management easy for the residents and prevention steps for all ICU workers.
A simple description of a less understood topic in Intensive Care Medicine. Aim to make understanding and management easy for the residents and prevention steps for all ICU workers.
OLD and NEW definition of Hepatorenal syndrome , EASL 2018 +AASLD 2012 guidelines , pathophysiology mechanisms , Precipitants of HRS , prevention and treatment of HRS , new drugs for HRS on lane , few evidences .
Anaesthesia to patiens with liver disease or a liver transplantscanFOAM
A presentation by Anna Januszkiewicz at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Devascularization in portal hypertension.dr quiyumMD Quiyumm
role of surgery in portal hypertension is promising. Devascularization is one of the procedure of choice in unshuntable portal vein. Though LT is treatment of choice
OLD and NEW definition of Hepatorenal syndrome , EASL 2018 +AASLD 2012 guidelines , pathophysiology mechanisms , Precipitants of HRS , prevention and treatment of HRS , new drugs for HRS on lane , few evidences .
Anaesthesia to patiens with liver disease or a liver transplantscanFOAM
A presentation by Anna Januszkiewicz at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Devascularization in portal hypertension.dr quiyumMD Quiyumm
role of surgery in portal hypertension is promising. Devascularization is one of the procedure of choice in unshuntable portal vein. Though LT is treatment of choice
This is a lecture note for 5th semester MBBS students. Lecture notes on hepatology, liver disease, alcoholic liver disease, alcohol-related liver disease, portal hypertension, ascites. Introduction to ascites and management of ascites.
Diarrhea & Constipation by dr Mohammed Hussien.
Ass. Lecturer of Gastroenterology & Hepatology
Kafrelsheik University
Membership at American Collage of Gastroenterology (ACG)
Membership at Egyptian association for Research and training in Hepatogastroentrology
Fever and Hyperthermia and Pyrexia of unknown origin by Dr Mohammad Hussien for Medical Student .
Ass.Lecturer of Hepatogastroentrology at Kafrelsheikh University.
Microwave ablation versus hepatic resection in managment of HCC by dr Mohamme...Kafrelsheiekh University
Evaluation and comparison between Microwave Ablation and Hepatic Resection in management of Hepatocellular Carcinoma.
By evaluation of Patient pre intervention and post interventions
What is Hepatic Encephalopathy.
What is the Grading of Hepatic Encephalopathy.
How to Diagnose Hepatic Encephalopathy .
How to Treat Hepatic Encephalopathy.
Inflammatory Bowel Disease ( Pathogensis & Steps of Diagnosis and Management) For Resident at Gastroenterology and Hepatology department at Kafrelsheikh by Dr/ Mohammed Hussien ( Assistant Lecturer).
Hepatitis (C) Story …. Past & Present & future
Most Recant Updating Guidelines by ASSLD & FDA
RAVS &How to deal with It ----12/7/2016.....
((Residents Lectures))
Hepatorenal Syndrome one of the Major Complication of Liver Cirrhosis ( Early detection & Treatment ) .......26/6/2016.....Kafrelshiek University ( Resident Lectures).
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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2. 2016 By Dr Mohammed Hussien
Historical Background
Definition
Pathogenesis
Diagnosis
Pervention
Treatment
Hepatorenal Syndrome
3. Historical Background
1863: Absence of histological changes to the kidney in some
cirrhotics with renal failure
1956: 1st detailed description of the syndrome by Sherlock
and Hecker.
1970s: Reversal of HRS with liver transplantation
4. Hepatorenal Syndrome
Definition
• HRS is a functional renal failure that develops in patients with
advanced cirrhosis as a consequence of a severe reduction in renal
perfusion.
• There is good Evidence suggesting the functional nature of this syndrome.
First, renal histology is normal or present lesions that do not justify the reduction
in glomerular filtration rate (GFR).
Second, the kidneys of cirrhotic patients with HRS function normally when
transplanted to patients with chronic renal failure.
Finally, HRS may reverse following treatment with vasoconstrictors and albumin.
6. Types of HRS
HRS TYPE 1 HRS TYPE 2
Characterized by a rapidly progressive
reduction of renal function, defined as either
doubling (100% increase) of the initial serum
creatinine to > 2.5 mg/dL or a 50% reduction
in GFR to < 20 mL/min over a 2-wk period.
Characterized by a more benign steady course,
with a stable reduction in GFR over weeks to
months, accompanying diuretic-resistant
ascites and avid sodium retention.
Average s. creatinine is 4 mg/dl Average s. creatinine is 2 mg/dl
Mean survival after the onset is 2-3 weeks Mean survival after the onset is 6-8 months
7. Part of the acute on chronic liver failure
syndrome (ACLF), With acute impairment in
hepatic, cerebral, cardiovascular & adrenal
functions. (ACLF Is severe inflammatory
systemic immune response due to excess
circulatory endotoxins & bact products DNA)
Clinical feature mainly is refractory ascites due
to poor or no response to diuretics with non-
progressive hepatic and circulatory functions.
Usually occurs in relation to a precipitating
factors mainly:
- Infections mainly SBP
- GI Haemorrhage
- Major surgery
- HRS Type 2 + hyponatremia or
hypovolaemia
- Viral, toxic, alcoholic, ischemic hepatitis on
top of LC, e.g. Ischemia after TIPS.
- No cause mostly bacterial products ,
endotoxins translocation .
May be the same but with non progressive
deterioration of hepatic and circulatory
functions
HRS TYPE 1 HRS TYPE 2
8. 2016
Type 3: cirrhosis with types 1 or 2 HRS
superimposed on chronic kidney disease or acute
renal injury
Type 4: fulminant liver failure with HRS
9. The International Ascites
Club
1.Cirrhosis with ascites
2.Serum creatinine >133 μmol/l (1.5 mg/dl)
3.No improvement of serum creatinine (decrease to a level of ≤133 μmol/l) after
at least two days of diuretic withdrawal and volume expansion with albumin. The
recommended dose of albumin is 1 g/kg body weight per day up to a maximum of
100 g/day
4.Absence of shock
5.No current or recent treatment with nephrotoxic drugs
6.Absence of parenchymal kidney disease as indicated by proteinuria >500 mg/
day, microhematuria (>50 red blood cells per high power field) and/or abnormal
renal
ultrasonography
10. Causes of kidney involvement in liver diseases
Intrinsic kidney involvement in liver diseases
Tubulo-interstitial involvement:
1. Drugs (paracetamol, aspirin, carbon tetrachloride, halogenated
hydrocarbons, immunosupressent agents)
1. Toxins (Galerina family of mushrooms, hemoglobin, myoglobin,
bilirubin, contrast agents)
1. Infections (leptospirosis, malaria, hepatitis)
2. Hypersensitivity reactions (sulphonamides, salicylates, etc.)
Glomerular involvement
1. Drugs (carbon tetrachloride)
2. Infections: Hepatitis A, B, C
3. Type II mixed cryoglobulinemia
4. IgA nephropathy (alcoholic cirrhosis, HCV cirrhosis)
5. Others (sickle cell disease, hemochromatosis, acute fatty liver and toxemia of pregnancy)
Vascular
1. Vasculitis
2. Toxemia of pregnancy and HELLP syndrome
12. 1. Doppler ultrasound Early detection of renal vasoconstriction
2. dilutional hyponatremia
3. low urinary sodium
4. reduced plasma osmolality
5. low arterial BP
6. high plasma renin activity
How to suspect HRS
( Tense Ascites + Deep Jaundice+ Hypotension)
13. Early identification of a
precipitating event of HRS
is clinically important
because it is frequently
preventable or treatable
with specific medical
therapy.
(Munoz SJ, 2008)
14. In type 1 HRS, a precipitating event is identified in 70 to 100% of patients
with HRS, and more than one event can occur in a single patient.
Large-volume paracentesis without albumin infusion
Gastrointestinal bleeding
Acute alcoholic hepatitis
Bacterial infections
•large-volume paracentesis without albumin expansion precipitates type 1
HRS in 15%
•25% of patients who present with acute alcoholic hepatitis eventually
develop HRS
•Intravascular volume depletion by overdose diuretic use or lactulose induced
diarrhea have been considered triggering factors for HRS
Precipitating Factors
Identifiable precipitating
factors include:
15. General Measures
Once diagnosed, treatment should be started early in order to prevent the
progression of renal failure.
An excessive administration of fluids should be avoided to prevent fluid
overload and development/progression of dilutional hyponatremia.
Potassium-sparing diuretics should not be given because of the risk of severe
hyperkalemia.
Careful Monitoring:
•urine output.
•and arterial pressure, as well as other standard vital signs.
•Ideally central venous pressure should be monitored to help with the
management of fluid balance and prevent volume overload.
•Patients are generally better managed in an intensive care or semi-intensive
care unit (Level A1).
18. 2016 DR Mohammed Hussien
Management of Hepatorenal
syndrome
Pharmacological
RRT
Artificial liver support
TIPS
liver transplantation
19. General measures
2004
Stop diuretics, and nephrotoxic agents. potassium-sparing diuretics (such as
spironolactone) are contraindicated because of the risk of hyperkalemia,
and loop diuretics (such as furosemide) may be ineffective.
Therefore, large-volume ascites should be treated with repeated large-
volume paracenteses and the intravenous administration of albumin (8 g
of albumin per liter of ascites removed)
CVP measurement "preclude volume related ARF"
Fluid challenge : Expansion of intravascular volume with
Albumin: 1gm/kg up to 100 gm IV repeated after 12 hours provided that CVP is
<10mmhg during the first day then 20-40gm in the second day with follow up of S .
Creat.
Saline or volume expanders
Search for sepsis: tapping of ascites for WBC, GM stain & culture. Culture of blood
, urine, cannula tips. Start Broad spectrum antibiotic promptly.
20. Specific treatment lines
1. Pharmacologic treatment (Bridging therapy)
Vasoconstrictors
Albumin
1. Liver transplantation (the only definitive therapy)
2. TIPS (HRS 2)
3. Renal replacement therapy
Arterio-venous Hemofiltration
Veno-venous Hemofiltration
1. MARS (HRS 1)
21. Pharmacologic ttt:
Vasoconstrictors plus albumin:
- Include IV terlipressin, IV norepinephrine, SC octeriotide + oral
Midodrine.
- TTT should be continued until creatinin normalization. Median
Duration of treatment is 7 days.
- Induce reversal (decreased s. creat to <1.5mg/dl) in 40-60% of
patients.
22. - Terlipressin + albumin (best evidence) prolong short term survival as recently
confirmed by meta-analysis.
Dose and duration . It should be started at a dose 0.5 – 1 mg i.v. (slow
push) every 4 – 6 h. If there is no early response (>25 % decrease in
creatinine levels a% er 2 days), the dose can be doubled every 2 days up
to a maximum of 12 mg / day (i.e., 2 mg i.v. every 4 h). Treatment can be
stopped if serum creatinine does not decrease by at least 50 % after 7
days at the highest dose. In patients with early response, treatment
should be extended until reversal of HRS (decrease in creatinine below 1.5
mg / dl) or for a maximum of 14 days .
A more rational method for adjusting the dose of vasoconstrictors is by
monitoring mean arterial blood pressure (an indirect indicator of
vasodilatation). This method has been used for adjusting the dose of
midodrine plus octreotide. Doses of octreotide and midodrine are titrated
to obtain an increase in the mean arterial pressure of at least 15 mm Hg.
- One small randomized trial showed that noradrenalin infusion may be equivalent
to terlipressin.
23. Attempts to use dopamine in combination with
vasoconstrictors conferred a better success rate, but this could
be attributed to vasoconstrictor therapy.
Similarly, the oral prostaglandin-E1 analog misoprostol or
intravenous prostaglandin infusion did not induce significant
changes in GFR or sodium excretion. Improvement in renal
function occurred in one report but could be explained by
volume expansion.
The endothelin-A antagonist BQ-123 demonstrated a dose-
dependent renal improvement in three treated patients, but
there still is controversy over the role of endothelin blockers in
HRS because subsequent studies showed a paradoxic vasodilating
effect of endothelin in patients with cirrhosis
24. 100 mic.g/8 h subcutaneously,with
an increase to 200 mic.g/8 h
1 g/kg on day 1 followed by 40 g/day
to improve the efficacy of treatment on
circulatory function.
2.5 to 7.5 mg/8 h
with an increase to
12.5 mg/8 h
1 mg/4–6 h and increased to a
maximum of
2 mg/4–6 h if there is no
reduction in creatinine
25. Terlipressin - Cardiac: angina MI & arrhythmia
- GI: cramps, vomiting, diarrhea,
intestinal ischemia.
- Periph: finger ischemia, skin and
scrotal necrosis.
- Others: HTN, bronchospasm, dyspnea
Noradrenaline Chest pain and ventilatory
hypokinesia
Octeriotide (glucagon release
inhibitor)
Diarrhea , tingling
Midodrine (alfa adrenergic agonist) HTN
•Vasodilators as dopamine at renal doses has no effect in HRS.
•Side effects:
26.
27. Liver transplantation:
The only (definitive) treatment associated with improved survival
for both HRS1 & 2.
Pretreatment is important and improves LTX outcome (morbidity
& mortality).
After LTX calcinurine inhibitors (cyclosporine & tacrolimus) should
be avoided, azathioprine , steroids and IL2 receptor blockers
should be used instead until diuresis is started.
The main problem of LTX in HRS1 is its applicability owing to their
extremely short survival. HRS should be allocated to the first
places of the waiting list.
28. TIPS:
TIPS, is an alternative treatment of type 1 HRS in patients without response to
terlipressin plus albumin.
o TIPS is effective in reversing type 2 HRS, The introduction of covered stents in
management of refractory ascites and type 2 HRS, mainly in those patients with
relatively good liver function.
o 2 pilot studies have recently evaluated transjugular intrahepatic portacaval shunt
(TIPS) in type 2 HRS: one showed marked reduction of s. creatinin in 8 out of 9
patients with long-term survival in 2 pts. The second showed significant
improvement in all patients as regard s. creatinin and ascites with 70% 1 year
survival probability. (Guevara & Arroyo, 2011).
o TIPS may improve renal perfusion and decrease RAAS activity.
o It can be considered also if HRS recurs after successful vasoconstrictor ttt
specially if liver transplantation is not likely in the near future.
29. Renal replacement therapy :
Renal-replacement therapy in the form of hemodialysis or continuous venovenous
hemofiltration has been used in the management of the hepatorenal syndrome,
particularly in patients awaiting transplantation or in those with acute, potentially
reversible conditions (e.g., alcoholic hepatitis).
Complications during hemodialysis, particularly hypotension, bleeding, and infections, are
common. Unfortunately, the optimal renal-replacement method for patients with the
hepatorenal syndrome is not clear, nor is it clear whether renal replacement therapy will
improve the prognosis for patients who are not candidates for a liver transplant.
Moreover, there are no data from studies comparing renal-replacement therapy with
vasoconstrictor administration. Until such data are available, it seems reasonable to start
therapy with vasoconstrictors and albumin alone unless there is an urgent need for
hemodialysis (i.e., because of severe hyperkalemia, metabolic acidosis, or volume
overload), and to reserve hemodialysis for patients who do not have a response to
vasoconstrictor therapy.
30. Extracorporial albumin dialysis:
In a small, randomized study, the molecular adsorbent
recirculating system (MARS), a modi$ed dialysis method
using an albumin-containing dialysate, was shown to improve
the 30 -day survival in 8 patients with HRS-1 compared with
5 patients treated with intermittent venovenous hemo$
ltration alone . However, clear beneficial effects on systemic
hemodynamics and on HE were observed. MARS is still
considered to be an experimental therapy and its use in
patients with type-1 HRS cannot be recommended outside
prospective pathophysiological or therapeutic investigations.
31. Prevention
1. Careful use and monitoring of diuretics therapy.
2. Early recognition of electrolyte imbalance, haemorrhage and infections
3. Avoid nephrotoxic agents
4. In large volume paracentesis, use salt-poor albumin (8g/L removed ascites)
5. Treatment of SBP properly (IV albumin & antibiotics)
1.5g/kg body wt IV at diagnosis of infection
1g/kg IV for 48 h (10% develop HRS Vs 33% without albumin)
1. Primary prophylaxis of SBP using longterm norfloxacin (400mg/day) or Ciprofloxacin (250-500 mg daily) in patients
with:
- CTP >9
- S.Bilirubin >4 mg/dl
- S. Creatinin >1.2 mg/dl
- S.sodium <130 meq/l
- Low ascetic fluid protein <1.5 mg/dl.