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Abstract _________________________ SIIIIIIII”ry All/I Cl/lldll,fllIII SUMMARY AND CONCLUSION Cirrhotic patients exhibit a wide spectrum of progressive and interrelated splanchnic, systemic and renal haemodynamic changes causing disturbed renal function which is attributed to reduced renal blood flow due to severe intrarenal arterial vasoconstriction, increased renovascular resistance and subsequent decreased renal perfusion in response to imbalance between vasoconstrictor and vasodilator forces acting on the inrarenal arteries, The present study was designed to determine the renal, splanchnic and systemic hacmodynumic changes that occur in chronic liver disease at different stages and to correlate these changes with the clinical and laboratory changes, Also, to study the effect of some therapies on the I-IRS group. In this study, the heart rate was increased in ascitic than cirrhotic without ascites and chronic hepatitis group, with more increase in the HRS group. The MAP was decreased with the progression of the disease, being lower in HRS more than ascitic, cirrhotic without ascites and chronic hepatitis groups. (IRS, is a well recognized complication of liver cirrhosis and shows early renal haemodynamic changes before maintenance of manifest renal dysfunction. This is due to decreased renal perfusion due to imbalance between vasoconstrictor and vasodilatory forces acting on kidneys. Decrease in renal plasma flow is associated with peripheral arterial vasodilatation. Increased renal arterial vascular resistance causes renal insufficiency that can be detected non-invasively by Doppler ultras- ·-145- ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• ;;;;;;; Sllmma~v Anti CIIIU’f1l,.111I/ -onography. i In this study, the intrarenal impedance lindices (RI and PI) were found elevated in cirrhotic patients than in pat~nts with chronic hepatitis und development of ascites is associated 1ith further increase. The highest values were present in the HRS group.jl’hese results confirm that, in liver cirrhosis, the intrarenal arterial vas040nstriction, the increased I renal ~ascl~lar resistance, the decreased renal perfusion .with su~sequent renal impairment occur proceed the developme,nt of ascites and Increase in severity with evolution of ascites. : I The present study detected renal i impairment and renal vasoconstriction in 53.3% of patients with nor~, al renal function, namely serum creatinine. After 2 months follow up of these patients 3 out of 8 , (38%) had HRS major criteria. i I WI: aSSUIll<: that, Rl of 0.7 might represent the cutoff critical level impending high risk of developing overt renaf failure. The sencitivity of this measurement was found to be as 100% and the specificity 58.3%. The very high sencitivity of this technique in prediction of HRS is very reliable in the clinical context. The low specificity (58.3 % in this study) is not a major setblock as the test is meant to be a ”screening procedure”. Cirrhotic parients with normal creatinine leve’ls but with increased renal RI at higher risk of kidney failure than those with normal RI. So patients having RI of ~ 0.7 should be dealt with cautiously with exclusion of any factors which would increase renal hypoperfusion. Follow up of these patients and choosing the suitable therapeutic approaches are mandatory. The intrarenal RI was also best correlated with severity of hepatocellular dysfunction and for studying early renal haemodynamic alterations and shows progressively increased levels with the evolution of -146- --1-- ••••••••••• iiiiiI •••••••••••• iiiiiliiiiiliiiiiI ••••••••••••••••••••••••••••••• iiiiiI •••••••••••••••••••••• iiiiiI ••• Sum”,ary Alltl Conclusion the disease with the deterioration of renal function and with the activation of endogenous vasoactive systems. The present study dcmonstrutcs (hut the most important predictors of HRS : are the intrarenal RI; the femoral blood flow volume; the sp~enic artery PI and the sreum albumin. The study concluded that, vasodilation in patients with liver cirrhosis occurs mainly in splanchnic arterial circulation and play an important role in the pathogenesis of decreased systemic vascular resistance seen in patients with cirrhosis. Also, the study showed that, the femoral blood llow was increased in ascitic patients indicating participation of extrasplanchnic system in the systemic vasodilaton. The present study showed that, there was no statistical signi ficant changes in intrarenal impedance indices between subgroup was given plasma from subgroup was given albumin. Both plasma and albumin are increasing the serum albumin nearly the same. \, When octreotide and midodrine were added to albumin, there was highly significant increase of MAP, more decrease of heart rate with high increase of urinary sodium and urine volume. The most strikingly was improvement of renal haemodynumic changes represented by highly significant changes in intrarenal RI and PI. The serum creatinine became significantly improved. The conclusion that can be reached on the basis of this study may be important for future research. Is that administration of vasoconstrictors with albumin is a good and effective treatment of HRS. However, more studies are needed to determine the best vasoconstrictor and the optimal dose. |