Part 2 book “Surgical critical care and emergency surgery” has contents: Obstetric critical care, diagnostic imaging, ultrasound, and interventional radiology, blunt and penetrating neck trauma, blunt and penetrating neck trauma, abdominal and abdominal vascular injury, peripheral vascular trauma, urologic trauma, and other contents. | Chapter 21 Transplantation, Immunology, and Cell Biology Leslie Kobayashi, MD 1. Which of the following would be the most helpful in differentiating pre-renal azotemia from hepato-renal dysfunction in a patient with liver failure? A. Fractional excretion of sodium that is less than 1% (FeNa 400) Answer: D D. Lack of response to fluid resuscitation Gines A, Escorsell A, Gines P, et al. (1993) Incidence, predictive factors, and treatment of the hepatorenal syndrome with ascites. Gastroenterology 105, 229–36. Uriz J, Gines P, Cardenas A, et al. (2000) Terlipressin plus albumin infusion: an effective and safe therapy of hepatorenal syndrome. Journal of Hepatology. 33, 43–8. Wong F, Pantea L, Sniderman K (2004) Midodrine octreotide, albumin, and TIPS in selected patients with cirrhosis and type 1 heptorenal syndrome. Hepatology 40, 55–64. E. BUN/Creatinine ratio greater than 20 Hepato-renal dysfunction refers to acute kidney injury within the setting of severe liver failure. It may have an insidious onset or present acutely if precipitated by a stressor, such as infection, gastrointestinal bleeding, or dehydration. It can affect up to 40% of patients with cirrhosis. The likely etiology is nitric oxide-induced splanchnic vasodilation with activation of the renin-angiotensinaldosterone system resulting in renal vasoconstriction and reduction in glomerular filtration rate. It presents similarly to pre-renal azotemia, and is, in essence, a pre-renal disease with decreased renal blood flow. The FeNa will be ⬍1%, urine sodium will be low, urine osmoles will be high, and urinary sediment will generally be benign. However, because of the low serum oncotic pressure, and the high output, low resistance state of cirrhotic patients, hepato-renal syndrome generally will not respond to fluid challenge. This is markedly different from pre-renal azotemia, which will generally respond to volume replacement within 24 to 72 hours. The best treatment for hepato-renal syndrome is liver .
