الفهرس 
Introduction
Aim of the workOnly 14 pages are availabe for public view
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Abstract
Hepatorenal Syndrome (HRS) is defined as the occurrence of renal failure in a patientwith advanced liver disease in the absence of an identifiable cause. HRS is a fully reversible impairment of renal function in patients with severe hepatic failure unresponsive to volume expansion.
HRS is a complication of end-stage liver cirrhosis characterized by intense renal vasoconstriction and a markedly decreased glomerular filtration rate resultingfrom both splanchnic and systemic circulatory changes of cirrhosis.
The prevalence of HRS in patients affected by cirrhosis and ascites was found to be 18% after 1 year, increasing to 39% at 5 years. Clinical audit aims to compare the current practice to guidelines. It is important to differentiate HRS from other causes of AKI because the therapeutic approach is different. Recent biomarkers are helpful but they are not widely available.
In this audit, we reviewed the medical reports of 70 patients admitted in Tropical Medicine and Gastroenterology Department of Assiut University Hospital in the period from July 2015 till July 2016.They were diagnosed as HRS in their medical reports comparing it to the recent guidelines.
Seventy patients had liver cirrhosis and ascites were diagnosed as HRS according to their medical records by presence of liver cirrhosis,ascites and renal impairment in absence of parenchymal renal disease,they were included in the study and distributed as 54/70 (77.11%) males and 16/70 (22.99%) females,.The mean of age ± SD was 58.63 ±8.11 years.
The collected data included demographic characteristics of the patients as age, sex, site of admission and associated comorbidities and clinical presentation of them. Routine laboratory investigations as LFTs, CBC, PT, INR, urea, and serum creatinine were done to all patients. All patients were evaluated with abdominal ultrasonography.
By reevaluation of the seventy patients in our study100% of them had liver cirrhosis with ascites that was moderate in 30 (42.8%)& tense in 40 (57.2%), no history ofuse of any nephrotoxic drugs in 100% of them,also no evidence of parenchymal renal disease by Abdominal ultrasound& urine analysis in all of patients,also serum creatinine was more than 1.5 mg/dl in 100% of patients, no improvement of serum creatinine after diuretic withdrawal but challenge test for hypovolaemia was done by ringer solution only in all patients (100%).
In our study no challenge test for hypovolemia done with salt free albumin due to socioeconomic causes, also no renal biopsy was done and no serum biomarkers were used to indicate renal impairment alternative to creatinine as other are not available and not recommended in guidelines.
Treatment options for HRS are limited and aim to prolong survival in patients waiting for liver transplantation. The majority of patients respond to a combination of albumin and vasopressors; however, prognosis is poor even in responders.
Combination of terlipressin and albumin was given in 20 patients (28.57%), regimen of Octreotide,midodrine and albumin was given in 50 patients(71.4%),doses given were less than recommended.
Hemodialysis was done in 5 patients (7.1%) in urgent indications only. We found that outcome of HRS is death in 87.2% (61/70)& only 9 patients had improved renal function (12.8%) which indicates the very poor prognosis of HRS.
Liver transplantation is the treatment of choice for both type 1 and type 2 HRS, with survival rates of approximately 65% in type 1 HRS but in our study none of our patients had done liver transplantation.
In conclusion:
• Clinical auditis important to improve the effectiveness and efficiency of health care.
• Hepatorenal Syndrome is a serious complication in patients with liver cirrhosis and ascites.
• In our study no challenge test for hypovolemia done with salt free albumin due to socioeconomic causes, also no renal biopsy was done and no serum biomarkers were used to indicate renal impairment alternative to creatinine as other are not available.
• The majority of patients respond to a combination of albumin and vasopressors; however, prognosis is poor even in responders.
• Combination of terlipressin and albumin was given in 20 patients (28.57%), regimen of Octreotide,midodrine and albumin was given in 50 patients(71.4%),doses given were less than recommended doses mentioned in guidelines due to limited resources.
• Hemodialysis was done in 5 patients (7.1%) in urgent indications only. We found that outcome of HRS is death in 87.2% (61/70)& only 9 patients had improved renal function (12.8%) which indicates the very poor prognosis of HRS.
• Liver transplantation is the treatment of choice for both types of HRS, but in our study none of our patients had done liver transplantation.Importantly, tools are needed to identify patients who will have sufficient recovery of kidney function after transplantation, simultaneous liver and kidney transplantation should be considered in patients with prolonged renal support more than 12 weeks.
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