Massive ascites and hepatorenal syndrome (HRS) are dreaded complications in advanced portal hypertensive cirrhotics, accounting for 30% of referrals for liver transplantation (LT). Renal failure in such settings incurs significant mortality, with levels of over 90% at 10 weeks with the rapid progressive type 1 HRS. Development of acute compartment syndrome (ACS) steps up the course to multiple organ dysfunction and failure, with intraabdominal pressure (IAP) as an independent predictor for ICU morbidity and mortality.
The interplay of ascites on IAP, IAP on renal function and ascites on HRS pose an intricate clinical conundrum. Independently, massive ascites, abdominal compartment syndrome and hepatorenal syndrome limit survival outcome in advanced cirrhotics. Reversing the progress towards a grim fate depends on the responsiveness of intra-abdominal and portal hypertension to medical and surgical decompression strategies, and averting renal failure. Such are the challenges for the critical care hepatologist. What single-session volume of paracentesis is acceptable to relieve diureticresistant ascites without fuelling renal injury? What are the clinical triggers for paracentesis and should the regime be targeted at IAP reduction or volume? Should abdominal perfusion pressure (difference between MAP and IAP) be the parameter to guide treatment of ACS?
Publication information
ACF Chan-Dominy, J Wendon (2006) “Splanchnic Haemodynamics and Hepatorenal syndrome” International Journal of Intensive Care 2006; 13(3)