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Abstract
Kidney dysfunction commonly develops in patients with established liver disease. In the most severe form the kidney dysfunction is termed the hepatorenal syndrome, which has been defined as unexplained kidney failure in a patient with liver disease who does not have clinical, laboratory or anatomical evidence of other known causes of kidney failure. The pathogenesis of hepatorenal syndrome involves the development of a hyperdynamic circulation with a lowering of renal perfusion pressure. Nitric oxide has been proposed to constitute a mediator of both the hyperdynamic circulation and renal failure in patients with advanced hepatic disease. Objective: The present work was designed to evaluate the possible changes of the renal artery Doppler indices and serum nitric oxide in cirrhotic patients with different clinical stages, also to assess the potential role of these changes in the pathogenesis of refractory ascites and hepatorenal syndrome. Patients and Methods: This work was carried out in Internal Medicine, Radiodiagnois and Medical Biochemistry Departments, Zagazig University Hospitals from 15 January 2005 to 15 October 2007. Eighty cirrhotic patients (40 male and 40 females) participated in the present study. Their ages ranged from 23 to 66 years, with mean ages 45.5 ± 7 years. They were randomly selected from the intensive care unit and in patients section of the internal Medicine Department. Results: This study was carried out on 80 patients and 20 normal control subjects. They were classified into the following groups: Group I: This group included 20 normal control subjects, 10 males (50%) and 10 females (50%). Their ages ranged from 21 to 63 years with mean 41.3 ± 12.4 years. Group II: This group included 20 cirrhotic patients without ascites, 10 males (50%) and 10 females (50%). Their ages ranged from 22 to 62 years with mean 43.4 ± 11.9 years. Group III: This group included 20 cirrhotic patients with responsive ascites, 7 males (35%) and 13 females (65%). Their ages ranged from 22 to 66 years with mean 46.4 ± 10.5 years. Group IV: This group included 20 cirrhotic patients with refractory ascites, 12 males (60%) and 8 females (40%). Their ages ranged from 21 to 63 years with mean 44.8 ± 12.9 years. Group V: this group included 20 patients with HRS, 11 males (55%) and 9 females (45%). Their ages ranged from 23 to 66 years with mean 47.9 ± 13.3 years.
Conclusions: Hepatorenal syndrome is a functional renal failure secondary to advanced liver failure and represent the extreme of the renal circulatory dysfunction in cirrhosis. Approximately 18% of patients with cirrhosis and ascites develop HRS within 1 year with median survival 1.7 weeks. The pathogenesis of HRS involves the development of hyperdynamic circulation with lowering of the renal perfusion pressure. Nitric oxide has been proposed to constitute a mediator of both the hyperdynamic circulation and renal failure in patients with advanced hepatic disease. Nitric oxide might be good prognostic marker in patients with liver cirrhosis, since it reflects two possible sequale of liver insufficiency namely increase nitric oxide production and impaired kidney function. Over production of nitric oxide cirrhotic patients might be related to the severity of hepatocellular dysfunction assessed by child Pugh score.