RU2499991C2 - Differential diagnostic technique for type of hepatorenal syndrome of alcoholic genesis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: blood serum creatinine and albumin are evaluated. An albumin-creatinine index is described as a albumin to creatinine relation. If the value is 155 standard units or less, type 1 hepatorenal syndrome is diagnosed. If the values exceeds 155 standard units, type 2 hepatorenal syndrome is diagnosed.

EFFECT: technique enables diagnosing a type of hepatorenal syndrome of alcoholic genesis more accurately when examining the patients suffering renal-hepatic failure.

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Description

Usage: therapy, gastroenterology, nephrology, narcology.

Objective: improving the accuracy of diagnosis of the type of hepatorenal syndrome of alcoholic genesis.

The inventive is introduced albumin-creatinine index, which allows to reliably determine the type of hepatorenal syndrome at the first request of a patient for medical help.

Positive effect: improving the accuracy of diagnosis of the type of hepatorenal syndrome of alcoholic genesis during the examination of patients with renal hepatic insufficiency at the first request of a patient for medical help.

The invention relates to medicine, namely to gastroenterology, nephrology, narcology.

Timely accurate determination of the type of hepatorenal syndrome (GDS) of alcoholic genesis makes it possible to resolve the issue of the need and selection of effective treatment, contributes to an increase in the survival rate of patients, and the rational selection of patients for liver transplantation.

GDS often develops in people of working age. In the natural course of liver cirrhosis, HRS develops in 40% of patients, in acute liver failure without a previous liver pathology, in almost half of patients (Mamaev S.N., Karimova A.M., 2008).

Depending on the severity of clinical manifestations and prognosis, there are types I and II HRS (Gines A. et.all, 1993). With alcoholic cirrhosis of the liver, type I is more often observed, characterized by an unfavorable course with a lethality of 80-90%. The course of type II is more favorable, it develops in cirrhosis without severe hepatic cell failure, and life expectancy varies from 1 to 7 years.

The main criteria for dividing into types are the rate of development of renal failure and prognosis. The diagnosis is established on the basis of an increase in creatinine levels of more than two norms. In the case of type I HRS, there is a rapid increase in creatinine in less than 14 days, type II - a similar increase in a few weeks or months (Sherlock LLL, Dooley J., 1999). The survival rate for type I HRS is only 20% for two weeks, this actually means that in some cases it is possible to distinguish between types of HRS only posthumously. At the same time, a number of patients are admitted for treatment with an already changed creatinine index and it is not possible to establish the type of HRS at the time of hospitalization.

The purpose of this proposal is to increase the effectiveness of differential diagnosis of type of GDS.

A comparative study of laboratory diagnostic parameters - signs of various types of GDS in 60 patients with GDS (30 - type I and 30 - type II) against cirrhosis of the liver with alcohol dependence syndrome was carried out. The study did not include patients with combined (viral and alcoholic) liver damage, with the presence of spontaneous bacterial peritonitis to exclude the influence of the infectious factor and ongoing antibiotic therapy on the functional state of the kidneys. During the study, biochemical features in patients with various types of HRS were clarified.

Taking into account the pathogenesis of GDS, it follows that the integral indicators characterizing the type of syndrome are the albumin content, which reflects the synthetic function of the liver, and the level of creatinine, which expresses the degree of renal dysfunction. When the biochemical parameters were compared in both groups, a significant difference was determined by the level of albumin in the blood: the average albumin content in the group with type I HRS was Me - 22.50 (20.25-26.25), in the second group with type II HRS Me = 40.50 (25.0-49.11) (p = 0.016). The creatinine level during the development of HRS between the groups with types I and II did not have significant differences.

Statistical analysis was performed using the SPSS 15 applied statistical software package. Quantitative attributes are presented as the median (first to third quarters). Quantitative trait analysis was performed using the Mann-Whitney U test for two independent samples. For the analysis of qualitative characteristics, Fisher's exact test was used. The probability of random error of less than 5% (p <0.05) was chosen as a criterion of statistical significance.

In connection with the revealed differences in laboratory parameters in groups with different types of HRS, we proposed using the albumin-creatinine index as the ratio of albumin to creatinine:

$$\mathrm{BUT}lbb\mathrm{at}m\mathrm{and}n-\mathrm{to}Re\mathrm{but}t\mathrm{and}n\mathrm{and}n\mathrm{about}\mathrm{at}s\mathrm{th}\mathrm{and}nde\mathrm{to}\mathrm{from},\mathrm{at}.e.=\frac{\mathrm{FROM}\mathrm{about}deR\mathrm{well}\mathrm{but}n\mathrm{and}e\mathrm{but}lbb\mathrm{at}m\mathrm{and}n\mathrm{but},g/l}{\mathrm{At}R\mathrm{about}\mathrm{at}enb\mathrm{to}Re\mathrm{but}t\mathrm{and}n\mathrm{and}n\mathrm{but},m\mathrm{about}lb/l}$$

in which the divider in both groups was the same, its average value was 0.2 mmol / l, and the average value of the dividend, taking into account the measurement errors, was 31.0 g / l.

The resulting ratio of albumin to creatinine was 155 UE (conventional units).

For patients with type I GDS, the albumin-creatinine index is less than or equal to 155 cu, with type II GDS, more than 155 cu

Clinical examples

Example No. 1.

Patient S., 44 years old, was delivered by an ambulance team with intense ascites, resistant to diuretic therapy on an outpatient basis.

From the anamnesis it is known: abuse alcohol for 8 years, "drunken" drunkenness for the past 2 years. Repeatedly encoded. Deterioration of well-being during the month: noted the appearance of nausea, yellowness of the skin, an increase in weakness, a decrease in appetite, the periodic occurrence of pain in the right hypochondrium of an aching nature, without a clear connection with food intake, an increase in the volume of the abdomen, the appearance of a venous network on the anterior abdominal wall, decreased urine output, shortness of breath with little physical exertion. Outpatient took hepatoprotectors, diuretics - without effect. Due to the increase in ascites, shortness of breath an ambulance call.

For the diagnosis of HRS on the first day, a study of laboratory parameters included in the standard examination for liver cirrhosis was carried out.

Examination data: OAK leukocytosis 19.0 * 109, anemia up to 80.0 g / l, platelets 120.0 * 10 ⁹ . In a biochemical study: total protein 74.2 g / l, albumin 20.0 g / l; total bilirubin 330.0 mmol / L due to direct 272.0 mmol / L, alkaline phosphatase 214.0 U / L, hepatic fraction of lactate dehydrogenase 521.8 ME, ALT 127.4 mmol / L, Ast 45.2 mmol / L potassium 3.5 mmol / L, sodium 125.8 mmol / L, urea 8.9 mmol / L, blood creatinine 0.19 mmol / L; during hospitalization during a blood test for hepatitis markers - no hepatitis markers were identified.

According to an ultrasound scan of the liver: a picture of liver cirrhosis (hepatosplenomegaly, expansion of the portal vein of the liver, unevenly increased echogenicity, ascites).

Based on the obtained laboratory data, we calculate the albumin-creatinine index, which in this case was 20.0: 0.19 = 105 UE, which makes it possible to diagnose type I HRS in a patient.

Example No. 2.

Patient A., 37 years old, 2 years ago, was diagnosed with alcoholic cirrhosis of the liver. Alcoholization experience of 7 years. Deterioration within 5 days after the previous hospitalization of the twelve-day binge. She is not registered in the narcological dispensary, has not been treated for alcoholism. Upon admission, he complained of weakness, nausea, lack of appetite, an increase in the volume of the abdomen. I did not receive outpatient treatment.

Directed by a local therapist with decompensated cirrhosis.

For the diagnosis of HRS on the first day, a study of laboratory parameters included in the standard examination for liver cirrhosis. Laboratory data: leukocytosis 8.3 * 10 ⁹ , hemoglobin level 112.0 g / l, platelet level 219.6 * 10 ⁹ . In a biochemical study: total protein 79.2 g / l, albumin 33.0 g / l, total bilirubin 128.6 mmol / l, direct bilirubin 90.2 mmol / l, alkaline phosphatase 309.5 U / l, ALT 65 , 0 mmol / L. ACT 84.3 mmol / L, potassium 3.3 mmol / L, sodium 130.0 mmol / L, urea 8.2 mmol / L, serum creatinine 0.16 mmol / L; during hospitalization during a blood test for hepatitis markers - no hepatitis markers were identified.

According to ultrasound examination of the liver: a picture of liver cirrhosis (hepatosplenomegaly, expansion of the portal vein of the liver, unevenly increased echogenicity, a small amount of fluid in the abdominal cavity).

Thus, based on the obtained laboratory data of the patient, we calculate the albumin-creatinine index, which in this case was 33.0: 0.16 = 206 UE, which allows diagnosing type II patients with HRS.

The method allows for quick and accurate differential diagnosis of type of GDS, timely selection of patients for high-tech treatment methods; ensures the availability of determination of the type of GDS in any medical institution, the absence of the need for participation at the screening stage of a specialist doctor; reduction of financial and time costs for examination.

List of sources

1. Pimanov S.I. Hepatorenal syndrome // Consilium Medicum. 2005. - T.7, No. 1. - C. 24-27.

2. Mamaev S.N., Karimova A.M. Type 1 and type 2 hepatorenal syndrome: current state of the problem // Ros. journal gastroenterol., hepatol., coloproctol. - 2008. - T.XVIII, No. 6. - S. 4-13.

3. Sherlock Sh., Dooley J. Diseases of the liver and biliary tract: Pract. Hands: Translated from English. / Ed. Z.G. Aprosina, N.A. Mukhina. - M .: Geotar Medicine, 1999.

Claims (1)

A method for differential diagnosis of the type of hepatorenal syndrome of alcoholic genesis, based on the use of albumin and creatinine levels, characterized in that the ratio of albumin to creatinine at the obtained albumin-creatinine index values equal to or less than 155 arbitrary units is interpreted as type I hepatorenal syndrome, when value above 155 conventional units as type II hepatorenal syndrome.