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TIPS适应症:肝肾综合征

时间:2021-08-20 15:49来源:www.ynjr.net 作者:杨宁介入医学网
HRS is usually manifested in the advanced stage of cirrhosis with PH. HRS(Hepatorenal Syndrome)发生在门静脉高压肝硬化晚期。(严重肝病晚期可能出现的一种并发症) International Club of Ascites has defined HRS as an increase in serum creatinin
HRS is usually manifested in the advanced stage of cirrhosis with PH.

HRS(Hepatorenal Syndrome) 发生在门静脉高压肝硬化晚期。(严重肝病晚期可能出现的一种并发症)

International Club of Ascites has defined HRS as an increase in serum creatinine ≥ 0.3 mg/dL (≥ 26.5 mmol/L) within 48 h; or a percentage increase in serum creatinine ≥ 50% from the baseline that is known, or presumed, to have occurred within the previous seven days[150]. 
国际腹水俱乐部(协会)将HRS定义为

1. 48小时内血清肌酐值的增加≥0.3mg/dL(≥26.5mmol/L);
2. 前七天内发生的比已知或假设基线血清肌酐值的增加≥50%[150]。


As per the recent International Club of Ascites classification, patients with cirrhosis and acute kidney injury (AKI) are subgrouped into HRS AKI and HRS non-AKI[150,151].
根据最近的国际腹水协会分类,肝硬化和急性肾损伤(AKI)患者分为HRS-AKI和HRS-非AKI[150,151]。

HRS non-AKI is further subdivided into HRS-acute kidney disease and HRS-chronic kidney disease.
HRS-非AKI可进一步细分为HRS-急性肾病和HRS-慢性肾病。

In the former, the calculated glomerular filtration rate (eGFR) is < 60 mL/min per 1.73 m2 for < 3 mo in the absence of other (structural) causes along with percent increase in serum creatinine < 50% using the last available value of outpatient creatinine value within 3 mo as the baseline value.
前者中,3个月内在没有其它其它(结构性)原因情况下,估算肾小球滤过率(eGFR)<60mL/分钟/.73㎡ ,以三个月内门诊患者最后肌酐可用值为基线,肌酐值增加<50%。

In the latter, the eGFR is < 60 mL/min per 1.73 m2 for ≥ 3 mo in the absence of other (structural) causes. In patients not responding to medical management in the presence of ascites, TIPS is a useful procedure in the management of HRS.
后者,3个月外在没有其它原因的情况下eGFR<60mL/分钟/.73㎡。

In patients not responding to medical management in the presence of ascites, TIPS is a useful procedure in the management of HRS.
对于腹水对药物管理没有反应的患者,TIPS是管理HRS中的一个有用的治疗。
 
The utility of TIPS in patients with HRS non-AKI has been discussed previously in the section on RA as most of these patients present with the need for repeated paracentesis.
TIPS在HRS非AKI患者中的应用之前已经在RA部分中讨论过,因为这些患者中的大多数都需要重复穿刺。

In a recent systematic review on TIPS in HRS, nine publications with 128 patients were analyzed. The pooled short-term and 1-year survival rates were 72% and 47% in HRS-AKI and 86% and 64% in HRS non-AKI. The pooled rate of HE after TIPS was 49%. The pooled rate of renal function improvement post-TIPS was 93% in HRS-AKI and 83% in any type of HRS. Post-procedure, creatinine, blood urea nitrogen, serum sodium, sodium excretion, and urine volume significantly improved with a nonsignificant elevation in serum bilirubin[152]. 
在最近一项关于HRS的TIPS的系统综述中,我们分析了9篇共128例患者的论文。HRS-AKI的合并短期和1年生存率分别为72%和47%,HRS非AKI的合并短期生存率分别为86%和64%。TIPS后HE的合并率为49%。TIPS-术后HRS-AKI的肾功能改善率为93%,任何类型的HRS均为83%。术后、肌酐、血尿素氮、血清钠、钠排泄量和尿量显著改善,血清胆红素[152]不显著升高。


The use of TIPS in patients with HRS-AKI remains controversial since a majority of these patients are sick at presentation with sepsis or acute decompensation. A recent retrospective cohort study in HRS patients showed TIPS is a relatively safe, bridging therapeutic option in patients who underwent TIPS in comparison to patients who received dialysis[153]. Decreased recurrence of ascites and increased incidence of HE in the TIPS group was seen in a small randomized study where they compared patients with Type 2 HRS (HRS non-AKI) who underwent TIPS with another group of patients receiving paracentesis plus albumin[81]. TIPS may prevent permanent renal damage and the need for further liver-kidney transplantation due to portosystemic shunting and resultant hemodynamic changes[154]. However, further RCTs showing the role of TIPS in HRS patients are required.


在HRS-AKI患者中使用TIPS仍然存在争议,因为这些患者中的大多数患者表现为脓毒症或急性失代偿。最近一项针对HRS患者的回顾性队列研究显示,与接受透析[153]的患者相比,在接受TIPS的患者中,TIPS是一种相对安全的桥接治疗选择。在一项小型随机研究中,TIPS组的腹水复发减少和HE发生率增加,他们将2型HRS(HRSnon-AKI)患者与另一组接受穿刺加白蛋白[81]的患者进行了比较。TIPS可以防止永久性肾损伤和进一步的肾损伤和需要进一步的肝移植。然而,还需要进一步显示TIPS在HRS患者中的作用的rct。
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