Bn ngh n nguyn nhn g khi

pht hin chc nng thn suy gim

bnh nhn x gan?
Gim th tch (dng li tiu, ung t nc,
XHTH)
Nhim trng
nh hng thuc c thn
Bnh thn mn c sn
Hi chng gan-thn
..
HI CHNG GAN-THN

PGS.TS.BS BI HU HONG
Trng Khoa Tiu ha
Bnh vin i Hc Y Dc TpHCM
 Hi chng gan-thn l
g?
Suy thn chc nng
v c kh nng hi phc

bnh nhn b suy gan nng

(cp hoc mn tinh) v tng p
tnh mch ca

Khng c nguyn nhn

gy suy thn c pht hin

CHN ON LOI TR
Salerno F, Gerbes A, Gines P, et al. Gut 2007;56:1310-1318
BNH SINH
CA HRS
 Stimulation of
Vasoconstrictor system

Clinical Journal of the American Society of Nephrology (VD: vasodilators; VC: vasoconstrictors, SNS:
sympathetic nervous system)
BNH SINH
CA HRS
Source: Am J Kidney Dis 2012; The National Kidney Foundation
Bng chng cho thy Thn vn cn
chc nng bnh thng
Tiu chun chn on chnh ca HRS

1- C BNH GAN (cp hay mn ) tin trin suy

gan nng v tng p lc tnh mch ca

2- C SUY THN:
GFR thp biu th bng creatinine clearance < 40
mL/min hoc creatinine mu >1,5mg/dL
(>133mmol/L)
Tiu chun chn on chnh ca HRS
3- KHNG C BNH THN trc
Tiu chun chn on chnh ca HRS
4- KHNG C NGUYN NHN TRC THN
Tiu chun chn on chnh ca HRS
4- KHNG C NGUYN NHN TRC THN

After at least 2 days

Tiu chun chn on chnh ca HRS
4- KHNG C NGUYN NHN SAU THN
Lu : Creatinine khng phi l thng s ng
tin cy nh gi chc nng thn trong HRS
Tng bilirubin mu nng c th nh hng lm gim
kt qu creatinine
Suy thn vn c th hin din mc d kt qu
creatinine cn bnh thng (BN suy dinh dng, gim
khi c)
 Phn loi HRS
Tp 1: cp (vd. vim gan cp do ru)
Creatinine mu tng gp i > 2,5mg/dL (220
mmol/L) hoc creatinine clearance 24 gi gim <
20ml/min < 2 tun
Thng c yu t khi pht (vd nhim trng)
Thi gian sng trung bnh khi khng iu tr: 2 tun

Tp 2: mn
Din tin t t, creatinine mu # 1,5-2,5 mg/dL
Thng gp trong c trng khng tr
Thi gian sng trung bnh: 4-6 thng
International Ascites Club
 Yu t thun li ?
i tng nguy c ?
Dng nhiu XHTH
li tiu

Chc tho Th tch mu

dch bng Thuc c
lng nhiu
M hiu qu thn
(EABV)
VPM
nhim khun Vng da
nguyn pht tc mt
TIN LNG TY THUC
TP CA HRS
NGUYN TC IU TR
Da trn Sinh l bnh

HEPATO-RENAL
SYNDROME
NGUYN TC IU TR
NGUYN TC
IU TR
NGUYN TC IU TR

Terlipressin, IV 1mg q4-6h to start, increase dose if

SCr does not fall at least 25% after 3 days. For partial
response (SCr does not fall < 133 umol/L) or non-
responders, treatment be stopped within 14 days
 Terlipressin ci thin GFR trong HRS

90 * 5
Mean Art. Pressure (mmHg)

Ser. Creat (mg/dl)

60
3

2
*
30
1

0 0
Baseline Treated Baseline Treated

J. Uriz et al J. Hepatol. 2000

 Terlipressin + Albumin so vi
Albumin n thun trong iu tr HRS
HRS Type 1&2 Terlipressin 1-2mg/Q4H + albumin (n=23)
(N=46) Albumin (n=23)

Complete response
Cr <133 umol/L

Partial response
50% decrease in SCr

Martin-Llahi M et al. 2008. Gastroenterology;134:1352-1359.

 Phn tch gp: Terlipressin trong iu tr HRS
Randomized trials in Type 1 or 2 HRS with terlipressin +/- albumin vs placebo +/- albumin
5 randomized clinical trials with 249 patients
Outcome: Mortality

Terlipressin reduced mortality compared with no intervention, placebo, or albumin

Gluud LL et al. 2012. Cochrane Database Syst Rev;Sep 12;9.
Transjugular Intrahepatic Portosystemic
Stent-Shunt (TIPS)
TIPS c th ci thin chc nng thn mt s BN nhng cha
d liu cho vic s dng trong HRS-1

EASL Guidelines. 2010. J Hepatol;53:397-417

 IU TR LC THN

Lc thn c ch nh ngn hn
bc cu ch i ghp gan
Khng c bng chng cho thy Lc thn s
lm tng t l sng lu di khi khng ghp gan
Lc thn c th gip gii quyt mt s bin
chng ca HRS: toan mu, tng ur mu,
tng kali mu

EASL Guidelines. 2010. J Hepatol;53:397-417

 GHP GAN

CCH IU TR DUY
NHT C HIU QU CHO
C HRS-1 V HRS-2

Cn iu tr HRS trc khi ghp gan:

- Nhng BN c p ng vi iu tr HRS cn c ghp gan n
thun
- Nhng BN khng p ng vi iu tr HRS v cn phi lc thn
cng thng c ghop gan n thun
- Nhng BN cn phi lc thn ko di (> 12 tun) cn xem xt kt
hp ghp gan v thn
EASL Guidelines. 2010. J Hepatol;53:397-417
EASL Guidelines. 2010. J Hepatol;53:397-417
Phng nga nh th no?

(NSAID, Aminosides, Contrast)

Bo v Thn bnh nhn x gan

Thn trng khi s dng li tiu

Thm d liu li tiu thp nht t hiu qu cho
tng bnh nhn
Suy thn lin quan dng li tiu:
- 20% bnh nhn x gan nhp vin v c trng
- thng khng nng
- hi phc nhanh chng sau khi ngng li tiu
 Bo v thn bnh nhn x gan
Phng nga nhim trng:
Xut huyt tiu ha do v gin TM thc qun
* 35-66% c nhim trng
* 7-15% b SBP
* XHTH km c trng: 30-50% b SBP
Vim phc mc nhim khun nguyn pht

Gia tng th tch huyt tng trong tnh trng

nhim trng
Hy chm sc l gan ca
bn