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Combine Conference

Combine Conference. 2011.05.18 R4 李思穎 / VS 賴俊夫. A 48-year-old woman with vomiting with blood clot for 10 days. Past History. Systemic disease Hypertension for 10+ year Chronic hepatitis B related liver cirrhosis, Child A Coronary artery disease, s/p POBA Peptic ulcer disease

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Combine Conference

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  1. Combine Conference 2011.05.18 R4 李思穎 / VS 賴俊夫

  2. A 48-year-old woman with vomiting with blood clot for 10 days

  3. Past History • Systemic disease • Hypertension for 10+ year • Chronic hepatitis B related liver cirrhosis, Child A • Coronary artery disease, s/p POBA • Peptic ulcer disease • Regular medications • Inderal(10mg) 1# BID • Norvasc(5mg) 1# BID

  4. Personal History • Surgical History • Gallbladder stone s/p cholecystectomy in 2008 • Allergy: No known drug allergies • Occupation: nil • Travel: no travel in recent 3 months • Animal contact: no • Smoking: denied • Drinking: denied • Betel nuts: denied

  5. Family History HBV carrier 55-year-old 48-year-old 24-year-old 23-year-old 16-year-old

  6. Present Illness • Nausea, poor appetite and vomiting with blood clot for 10 days • Visit NTUH ER • TPR=36.7C/71/18 • Bp=136/94 2011/2/22

  7. Physical Examination

  8. Physical Examination

  9. Lab • Hemogram

  10. Lab • Biochemistry and Electrolyte • Coagulation profile

  11. Lab • Urine analysis

  12. CXR (2011/02/22)

  13. Abdominal Ultrasound

  14. Hepatitis Profile

  15. Present Illness • Chronic hepatitis B with flare up • Start Lamivudine • Hepatic encephalopathy • Switch to Entecavir • Start pre-liver transplantation evaluation 2011/2/25 2011/3/02

  16. 2011/3/6~3/21 Plasma Exchange

  17. 0222 0323 0310 2011/3/6~3/21 Plasma Exchange 2011/3/10~ SLED

  18. 2011/3/23 Liver Transplantation 2011/3/6~3/21 Plasma Exchange

  19. 2011/3/23 Liver Transplantation 2011/3/28 B/C: candida albicans 2011/3/6~3/21 Plasma Exchange

  20. 2011/3/23 Liver Transplantation 2011/4/06 Explore laparotomy Liver biopsy: no rejection 2011/3/6~3/21 Plasma Exchange

  21. 2011/3/23 Liver Transplantation 2011/4/06 Explore laparotomy Liver biopsy: no rejection 2011/3/6~3/21 Plasma Exchange

  22. 2011/3/23 Liver Transplantation 2011/4/06 Explore laparotomy Liver biopsy: no rejection 2011/3/6~3/21 Plasma Exchange 2011/3/10~ SLED cSLED(4/3-4/12)SLED IHD

  23. 0418 0222 0323 0406 0310 2011/3/23 Liver Transplantation 2011/3/10~ SLED cSLED(4/3-4/12)SLEDIHD

  24. 2011/3/23 Liver Transplantation 2011/3/10~ SLED cSLED(4/3-4/12)SLED IHD

  25. 2011/3/23 Liver Transplantation 2011/3/10~ SLED cSLED(4/3-4/12)SLED IHD

  26. 2011/3/23 Liver Transplantation 2011/4/06 Explore laparotomy Liver biopsy: no rejection 2011/3/6~3/21 Plasma Exchange 2011/3/10~ SLED cSLED(4/3-4/12)SLED IHD(-5/6)Hold

  27. Discussion Renal prognosis after liver transplantation for hepatorenal syndrome Indication of simultaneous liver-kidney transplantation

  28. Abbreviation • LTX: Liver transplantation • LTA: Liver transplant alone • OLT: Orthotopic liver transplantation • KTA: Kidney transplant alone • LKTX: Liver-kidney transplants • CLKT: Combined liver and kidney transplantation • SLK: Simultaneous liver and kidney • KALT: Kidney transplantation after liver transplantation • HRS: Hepatorenal syndrome

  29. Discussion Renal prognosis after liver transplantation for hepatorenal syndrome Indication of simultaneous liver-kidney transplantation

  30. Approximately 20% of patients undergoing liver transplantation (LTx) demonstrate acute or chronic renal insufficiency

  31. Model for end-stage liver disease (MELD) • Adopted by UNOS(United Network for Oragn Sharing) in 2002 as the basis for deceased donor liver allocation for adult patients Transplantation, 2011

  32. Model for end-stage liver disease (MELD) www.unos.org

  33. LKTx in UNOS Data Transplantation, 2011

  34. MELD Score • Predict mortality and choose candidates most in need of LTx • 3.8[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] + 9.6[Ln serum creatinine (mg/dL)] + 6.4

  35. Pre-MELD vs Post-MELD Era Patient Survival Graft Survival Post-MELD era ~ Mean MELD: 20.5 Pre-MELD era ~ Mean MELD: 17.0 Aliment Pharmacol Ther 2005; 21: 169

  36. Renal failure before LTx has been reported to predict an increased risk of postoperative renal failure, infection, and death

  37. Renal Function in Liver Disease • Serum creatinine: unreliable(overestimate) • lower muscle mass • decreased hepatic synthesis of creatine, the precursor of creatinine • increased tubular secretion of creatinine • Women will have a lower MELD score than men because of a smaller muscle mass Transplantation, 2011

  38. Acute Kidney Injury • Cause • Hepatorenal syndrome(HRS): 17% • Acute tubular necrosis • Hypovolemia-associated hemorrhage • Infection • ……

  39. Hepatorenal Syndrome • The development of acute renal failure in a patient who usually has advanced liver disease due to cirrhosis, severe alcoholic hepatitis or metastatic tumor

  40. Diagnostic Criteria -1 • Major criteria • Chronic or acute liver disease with advanced hepatic failure and portal HTN • Low GFR ( crea> 1.5mg/dL or 24hr Ccr< 40 mL/min ) • Absence of shock, current or recent treatment with nephrotoxic drugs, fluid losses, or ongoing bacterial infection • No improvement after diuretics withdraw & hydration with 1.5 L of isotonic saline • Proteinuria < 500mg/day and no ultrasonographic evidence of obstructive uropathy or parenchymal renal disease Gut 2007;56: 1310-1318

  41. Diagnostic Criteria -2 • Minor criteria • Urine volume < 500mL/day • Urine Na < 10 mEq/L • Urine osmo greater than plasma osmo • Urine RBC < 50/HPF • Serum Na< 130 mEq/L Gut 2007;56: 1310-1318

  42. Current Diagnostic Criteria • Chronic or acute liver disease with advanced hepatic failure and portal HTN • Low GFR ( crea> 1.5mg/dL) • Absence of shock, current or recent treatment with nephrotoxic drugs, fluid losses • No improvement after diuretics withdraw & hydration with Albumin 1g/kg/BW (up to a maximum 100g) • Proteinuria < 500mg/day and no ultrasonographic evidence of obstructive uropathy or parenchymal renal disease Gut 2007;56: 1310-1318

  43. Classification • HRS Type 1 • HRS Type 2

  44. Pathogenesis of HRS 2 Seminars in Liver Disease 2008;28: 81-95

  45. HRS Type 2 • Less severe (creatinine1.5 mg/dL [132μM/L]) • More slowly progressive with a mean survival of 6 months. • Usually appears spontaneously • Associated with refractory ascites Seminars in Liver Disease 2008;28: 81-95

  46. Pathogenesis of HRS 1 Seminars in Liver Disease 2008;28: 81-95

  47. HRS Type 1 • Rapid impairment of renal function • Serum creatinine level greater than 2.5 mg/dL (>220 μM/L) within 2 weeks • Frequently with precipitating factor • Infection, esp SBP • GI hemorrhage • Acute hepatitis Seminars in Liver Disease 2008;28: 81-95

  48. Survival Gastroenterology 1993;271: 1121- 1125

  49. Treatment -1 • Pharmacological Treatment • Renal vasodilator • Dopamine, PGE1,E2,I2: all been tried without success • Systemic (splanchnic) vasoconstrictor • Terlipressin • Midodrine • Norepinephrine • Volume expander • albumin

  50. Drug Dosage National Taiwan University Hospital

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