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( PAMPs ) due to bacterial translocation will result in increased production of pro-inflammatory cytokines associated with renal dysfunction , tubular damage , and apoptosis . 9
Classification of HRS 9
Classification Table 2 shows the classification of HRS . Traditionally , HRS has been designated type-1 HRS , which was often triggered by bacterial infection and defined as a rapid decrease of renal function ( two-fold increase of the initial serum creatinine level to a level > 2.5mg / dl or decreased initial 24-hour creatinine clearance by 50 % to < 20ml / min in less than two weeks ). Throughout the years , however , this classification has been further refined into subtypes including acute kidney injury , acute kidney disease and chronic kidney disease ( Table 2 ). 9
Spontaneous bacterial peritonitis ( SBP ) Another common complication of liver cirrhosis is an ascitic fluid infection , including SBP . This complication mainly happens due to bacterial overgrowth in the intestine , which subsequently translocates into the mesenteric lymph nodes . SBP is defined as an absolute polymorphonuclear neutrophil ( PMN ) count > 250 / mm 3 in the ascitic fluid and a positive ascitic fluid culture , accompanied by the absence of any other intra-abdominal sources of infection ( Table 3 ). 2
HRS-acute kidney injury ( HRS-AKI )
HRS-acute kidney disease ( HRS-AKD )
HRS-chronic kidney disease ( HRS-CKD )
Increased serum creatinine level by at least 0.3mg / dl within 48 hours and / or urinary output < 0.5ml / kg for at least six hours or increased serum creatinine level by at least 50 % compared with last available value of outpatient serum creatinine with three months
Decreased estimated glomerular filtration rate ( eGFR ) (< 60ml / min / 1.73m 2 ) for less than three months without any presence of other structural causes
Increased serum creatinine level by less than 50 % in comparison to the last available value of outpatient serum creatinine with three months
Decreased eGFR (< 60ml / min / 1.73m 2 ) for at least 3 months without any presence of other structural causes
Role of albumin in management of ascites and cirrhosis complications Typically , the management of ascites needs to be tailored , according to the severity of its clinical manifestation . Guidelines have suggested the role of albumin in targeting key pathogenic events to prevent cirrhosis progression , especially in the management of ascites .
Approximately 75 % of plasma oncotic pressure comes from albumin . Therefore , since the 1980s , the use of albumin as a plasma expander to prevent decreased cardiac output , increased plasma renin activity , and renal dysfunction has been applied to liver cirrhosis . A prospective and nonrandomised study in patients with HRS demonstrated more significant improvement of renal function , as well as significantly higher serum sodium concentration , arterial pressure , central venous pressure , and atrial natriuretic peptide levels in patients treated with terlipressin and albumin , compared with patients treated with albumin alone . 10 Antioxidant effects exerted by albumin can also modulate SIRS in liver cirrhosis . O ’ Brien et al elaborated the effect of intravenous albumin administration in modulating immune dysfunction by showing the reversal of immunosuppressive effects of prostaglandin E in patients with acute decompensated cirrhosis . 11
SBP Albumin infusion , in addition to cefotaxime , significantly reduced the risk of renal impairment ( 33 % vs 10 %), inpatient mortality ( 29 % vs 10 %) and 3-month mortality ( 41 % vs 22 %). 12 The benefits of albumin were subsequently confirmed in a meta-analysis of randomised trials , especially in patients at high risk of developing renal impairment ( baseline serum bilirubin ≥4mg / dl or creatinine ≥1mg / dl ). 13
In terms of improving survival and quality of life , long-term administration of albumin has been studied in several clinical trials . The Albumin for the treatment of aScites in patients With hEpatic cirrhosis ( ANSWER ) trial in 431 subjects with persistent ascites not responding to diuretics showed a markedly higher overall survival rate within three months in patients treated with standard medical treatment ( SMT )
Classification of SBP
Spontaneous bacterial peritonitis
Monomicrobial non-neutrocytic bacterascites
Culture-negative neutrocytic ascites
Secondary bacterial peritonitis
Polymicrobial bacterascites
Ascitic fluid culture
PMN count
(+) > 250 / mm 3
(+) < 250 / mm 3
( - ) > 250 / mm 3
(+) usually for more than one organism
(+) more than one organism from Gram staining examination or from ascitic fluid culture
> 250 / mm 3
< 250 / mm 3
combined with 40g albumin twice weekly ( for 2 weeks ) continued with 40g albumin weekly . This result was obtained in comparison with patients treated with only SMT ( 77 % vs 66 %). In addition , the cumulative incidences of SBP , non-SBP bacterial infections , renal dysfunction , and hyponatraemia or hyperkalaemia due to diuretics were decreased by 27 – 70 % in groups treated with SMT and albumin . Improvement of quality of life was also observed in the same group , indicated by significant reduction in the number of hospital admission
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