GASTROENTEROLOGY ARTICLE OF THE WEEK
February 14, 2002
Wong F, Blendis L. New challenge of hepatorenal syndrome: Prevention and Treatment. Hepatology 2001;34:1242-1251.
1. Gastrointestinal bleeding in the patient with cirrhosis and ascites
a. can precipitate renal failure by ATN
b. antibiotic prophylaxis is recommended in patients with tense ascites
c. GI bleeding usually precipitates type II HRS
d. the presence of bleeding is not a contraindication to continuation of diuretics
for the treatment of ascites
e. GI bleeding may lead to the systemic inflammatory response syndrome (SIRS)
increasing the risk of HRS
2. Type I HRS is characterized by
a. slowly progressive renal insuffiency
b. better prognosis than type II
c. rapidly progressive renal failure with doubling or serum creatinine to a level
>2.5mg/dl in less than 2 weeks
d. acute liver failure
e. usually having an identifiable precipitating cause
3. Pathophysiologic hallmarks of HRS include
a. severe peripheral vasodilation
b. severe renal vasodilation
c. decreased total renal blood flow
d. intrinsic renal disease
e. increased cardiac output
d. systemic hypotension
e. renal vasoconstriction in response to severe systemic vasodilation
True or False
4. Vasopressin analogues may help HRS by further vasoconstricting the renal circulation.
5. Cholestatic jaundice is a predisposing factor to type I HRS.
6. Post-paracentesis circulatory disturbance develops in only about 1/3 of patients undergoing LVP, those affected usually have the highest levels of pre-paracentesis plasma renin activity.
7. High plasma renin activity is an independent predictor of type I HRS.
8. The presence of sinusoidal or post-sinusoidal hypertension is an important factor in the development of the HRS
9. The use of NSAID’s in patients with cirrhosis and ascites may precipitate HRS by decreasing renal prostaglandin production.
10. “Renal dose” dopamine is effective in the management of HRS
11. Up to 24% of patients with type I HRS have no readily identifiable cause that triggered the HRS.
12. The dose of furosemide in the treatment of ascites should not exceed 160mg daily, the dose of spironolactone should be no larger than 400mg daily.
13. Acceptable prophylactic antibiotic regimens in patients with GI bleeding and tense ascites include
a. Gentamycin and Amoxicllin
b. Norfloxacin 400mg bid for 7 days
c. Tobramycin and ciprofloxacin
d. None, only patients with low protein ascites should be prophylaxed
14. Intravenous albumin infusion is helpful in patients with SBP and
a. no other systemic illnesses
b. fever
c. increased bilirubin (>4 mg/dL)
d. alcoholic hepatitis
e. renal impairment
15. TIPS for HRS
a. TIPS is contraindicated
b. May reverse HRS in some, but does not completely restore renal function
c. Appears to be more effective for type II HRS compared to type I
d. has become a standard of care therapy for patients with type II HRS