A 56-year-old man with hepatorenal syndrome（肝肾综合征）

A 56-year-old man with a 10-year history of type 2 diabetes mellitus（糖尿病）and end-stage liver disease secondary to hepatits C is admitted to the ICU with respiratory failure secondary to increasing ascites（腹水）, which has been treated with furosemide（呋塞米） and spironolactone（螺内酯）, with poor results. His laboratory values are: serum creatinine 2.4 mg/dL (increased from 1.3 mg/dL), bilirubin（胆红素） 8 mg/dL, INR 2.3, albumin 2.5 g/dL, hemoglobin（血红蛋白） 9 g/dL, and platelet count 40,000/μL. Antibiotics were started for a recent diagnosis of spontaneous bacterial peritonitis（自发性细菌性腹膜炎）. His condition further deteriorated（恶化） with the development of tense ascites and oliguria (daily urine output 300 mL) with a further rise in creatinine to 3 mg/dL. A diagnosis of hepatorenal syndrome（肝肾综合征） is made.

Which of the following is the best alternative（选择） treatment for this patient?

A. Dopamine

B. Fenoldopam（非诺多巴[血管扩张药]） and albumin

C. Isoproterenol

D. Octreotide（奥曲肽） and albumin

解析：

Hepatorenal syndrome (HRS) is a well-described entity in patients with end-stage liver disease（终末期肝病）, and is believed to be caused mainly by functional factors. HRS type 1 is characterized by a rapid decline of renal function over a period of several weeks whereas HRS type 2 is considered to be a more chronic disease. Pathophysiology is mostly believed to be due to arterial vasodilation（血管舒张） with reduced systemic vascular resistance and cardiac output that cannot compensate for this vasodilation. Secondary phenomenon is activation of the renal angiotensin-aldosterone system and increase secretion of arginine vasopressin（精氨酸加压素） to maintain blood pressure. The problem is multifactorial, and lately an increase in an inflammatory state has been described as yet another factor potentiating this problem. The treatment of HRS is in part preventive, by administration of concentrated albumin and treatment of spontaneous bacterial peritonitis, so D is the correct answer. In some patients dual（双重） transplant of liver and kidney can be considered but this is a controversial issue since we cannot predict which patients will recover their kidney function after liver transplant.

Reference:
1. Durand F, Graupera I, Ginès P, Olson JC, Nadim MK. Pathogenesis of hepatorenal syndrome: implications for therapy. Am J Kidney Dis. 2016 Feb;67(2):318-328.