8 Sep - Hepatorenal Syndrome

This case was of a gentleman with severe decompensated cirrhosis with refractory ascites.  Management of ascites was discussed previously in this post.

A couple key articles to add:

Know the trail test - quick, easy, and evidence based way to monitor cirrhotics for early encephalopathy.  This NEJM review from 1997 goes over the use of this test for early detection, as well as most interventions short of the newly used rifaximin.

As for use of TIPS - two traditional uses are to control variceal hemorrhage and to improve refractory ascites.  A recent trail suggests that this technique should be used more early in patients at high risk for variceal bleeding, before they have had their first bleed.

Finally - know hepatorenal syndrome.  This was well reviewed recently in NEJM.  Type 1 hepatorenal is the rapidly progressive, more dramatic version with highest short term mortality.  FENA <1 suggests hepatorenal syndrome in cirrhotics with kidney impairment.  Accurate estimation of GFR in cirrhotics is difficult, and the CG  equation performs more poorly than MDRD, and even that overestimates the actual renal function.  The potential role of TIPS in this condition was mentioned, but definitive clinical data is lacking.

The cost of midodrine/octreotide/albumin therapy is ~$2000 per day in drug cost alone, and should primarily be considered a bridge to definitive treatment such as transplant.

Jul 7 - Evaluation of Elevated LFTs

Discussion of a case of acute alcoholic liver disease with underlying cirrhosis.  Some links to things discussed this AM:

Comprehensive NEJM review on Cirrhosis and Ascites - Excellent review of cirrhosis management.

This NEJM article on evaluation of abnormal LFTs is a nice complement to the uptodate article on the reading list.

Finally - this article walks you through how and when to do a paracentesis and how to interpret the results.  Part of the outstanding "Rational Clinical Exam" series in JAMA.