Retensi natrium merupakan kelainan fungsional ginjal pertama dan paling sering pada pasien dengan sirosis serta memainkan peranan penting dalam pembentukan asites dan edema. Dalam perjalanan sirosis, pasien mengalami ketidakmampuan ginjal untuk mengeluarkan air bebas larutan yang dapat menyebabkan hiponatremia dilusional dan sindrom hepatorenal. Pengobatan sindrom hepatorenal bertujuan untuk mengembalikan vasodilatasi arteri splanknik dan mening

1. Renal Complications and Hepatorenal Syndrome Andrés Cárdenas Pere Ginès Juan Rodés Editors: Schiff, Eugene R.; Sorrell, Michael F.; Maddrey, Willis C. Title: Schiff's Diseases of the Liver, 10th Edition Copyright ©2007 Lippincott Williams & Wilkins

5. Table 17.1. Functional Renal Abnormalities in Cirrhosis Hepatorenal syndrome Renal vasoconstriction Spontaneous dilutional hyponatremia Solute-free water retention Ascites and edema Sodium retention Clinical consequence Abnormality

9. Figure 17.2 Urinary sodium excretion, diuresis after a water load (20 mL/kg body weight of 5% dextrose IV) and glomerular filtration rate (GFR, insulin clearance) in a series of patients with cirrhosis hospitalized for the treatment of an episode of ascites. All patients were studied after a minimum of 5 days on a 50 mEq/day sodium diet and without diuretic therapy. Values in healthy subjects studied under the same conditions are urine sodium, 40 to 60 mEq/day; diuresis after a water load, 10 to 18 mL/minute; GFR, 110 to 140 mL/minute. Most patients had marked sodium and water retention. Moderate reductions of GFR were present in two thirds of patients, whereas a marked reduction of this parameter was found in 18%. (From Ginès P, Fernández-Esparrach G, Arroyo V, et al. Pathophysiology of ascites. Semin Liver Dis 1997;17:175, with permission.)

12. Table 17.2. Clinical Types of Hepatorenal Syndrome Impairment in renal function with serum creatinine >1.5 mg/dL (130μmol/L) that does not meet criteria for type 1 Type 2 Rapid and progressive impairment of renal function as defined by a doubling of the initial serum creatinine to a level higher than 2.5 mg/dL (220 μmol/L) or a 50% reduction of the initial 24-h creatinine clearance to a level lower than 20 mL/min in <2 wk Type 1

13. Table 17.3. Parameters Associated with a Higher Risk of Hepatorenal Syndrome Development in Nonazotemic Patients with Cirrhosis and Ascitesa a All measurements were obtained after a minimum of 5 days on a lowsodium diet and without diuretics. b Blood urea nitrogen and serum creatinine values up to 30 mg/dL and 1.5 mg/dL (130 μmol/L), respectively. From Ginès A, Escorsell A, Ginès P, et al. Incidence, predictive factors, and prognosis of hepatorenal syndrome in cirrhosis. Gastroenterology 1993;105:229–236; Ruiz del Arbol L, Monescillo A, Arocena C, et al. Circulatory function and hepatorenal syndrome in cirrhosis. Hepatology 2005;42:439–447. Previous episodes of ascites Poor nutritional status Moderately increased BUN b Moderately increased serum creatinine b Low serum sodium (serum sodium <130 mEq/L) Low urinary sodium excretion (urine sodium <10 mEq/L) High plasma renin activity (>4 ng/mL per h) Low mean arterial pressure (<85 mm Hg) Reduced solute-free water excretion after water load (<3 mL/min) Increased plasma norepinephrine (>500 pg/mL) Presence of esophageal varices Model for End-Stage Liver Disease scor

23. Terima kasih.