The ‘Hepatorenal’ Syndrome and Refractory Ascites

Abstract

The charts of 30 consecutive patients who underwent implantation of a LeVeen type of peritoneal-venous (P-V) shunt were reviewed. 29 patients had Laennec’s cirrhosis and ascites refractory to medical therapy. Of these, 7 or 24% had hepatorenal syndrome (HRS), i.e. creatininemia and azotemia, a low urinary sodium (UNa), and no other apparent cause for renal failure. In these patients with plasma creatinine (pCr) > 1.6 mg/dl and BUN > 30 mg/dl and UNa < 10 mEq/1, the P-V shunt s ingificantly improved all 3 measures of renal function: pCr decreased from 4.3 to 2.7 mg/dl (p < 0.025) BUN decreased from 79 to 38 mg/dl (p < 0.025) and UNa increased to 70 mEq/1. 4 of these patients are still alive, a mean of 418 days after being shunted (preshunt BUN = 60 mg/dl). 3 patients died a mean of 81.7 days after shunt implantation (preshunt BUN = 83 mg/dl), none from renal failure. Of the 29 patients with refractory ascites, + / – HRS, the implantation of this shunt was associated with a significant increase in renal sodium clearance (CNa) and fraction of the filtered sodium being excreted CNa/Ccr. The CNa/Ccr increased after shunting in patients studied while off diuretics from 0.21 to 1.45% (p < 0.025). The avid renal salt adsorption characteristic of refractory ascites and HRS appears to have been reversed. The P-V shunt appears to be beneficial therapy, especially in preterminal HRS, and appears to function in a physiologic manner, by decreasing the renal reabsorption of sodium and water.