Chronic Liver Failure II: Encephalopathy, Hepatorenal, IgA Nephropathy, Transplantation: Waters Flashcards
Describe the mechanisms of hepatic encephalopathy.
Basically, things get to the brain that shouldn’t be there, should be filtered out by liver.
Nitrogenous wastes, ammonia.
Incr. intracellular glutamine.
Astrocyte swelling, cerebral edema.
Inflammatory cytokines alter BBB.
Incr. benzodiazepine receptors.
Incr. neurosteroids, incr. GABA receptor activity.
Define acute hepatic encephalopathy. What is happening?
Acute liver failure- coagulopathy and altered mental status within two weeks of jaundice.
Alteration of the BBB.
Assoc. w/ acute cerebral edema—> cerebral herniation.
Major cause of death from acute liver injury.
How does chronic hepatic encephalopathy differ from acute, clinically?
Slower and more subtle in onset.
Often noticed by family members, as they have milder symptoms often missed by physicians bc we do not see them everyday and understand their baseline mannerisms, habitus as well.
Is chronic encephalopathy reversible?
For the most part, yes. May be some mild disabilities retained in some.
How do you treat chronic encephalopathy?
Treat the precipitating conditions: Hypovolemia Hypokalemia GI bleeding Meds, substance abuse Infxn Exclude intracranial hemorrhage, falls w/ thrombocytopenia, coagulopathy (high INR).
Give lactulose- helps shed fluid, lower pH of intestine, lowers glutamine absorption. Reduces synthesis and abs of NH3.
Abx- alter intestinal flora, decr. NH3, decr. intestinal mucosal glutaminase, decr. coliform bacteria converting urea–> NH3
DO NOT RESTRICT DIETARY PROTEIN
Is cerebral edema common in chronic hepatic encephalopathy?
Not common, but can happen.
Worsened w/ hyponatremia and rapid fluid shifts.
What is the most feared complication of acute liver failure or cirrhosis?
Hepatorenal syndrome.
Liver failure causes renal arterial vasoconstriction and renal failure. No underlying renal parenchymal abnorm (it ain’t the kidneys’ fault!) Corrected by correcting liver problems (transplant).
Type I- rapid worsening
Type II- slow progression w/ progressive loss of liver fxn
What are the clinical findings in hepatorenal syndrome?
Cirrhosis + ascites with Creatinine >1.5mg/dL and no improvement with volume resuscitation.
Tx for hepatorenal sydrome.
Fluid resuscitation.
Treat underlying liver disease (transplant)
Avoid meds that worsen renal fxn (NSAIDs, intravenous contrast agents)
Optimize renal perfusion w/ Midodrine (pressor) and octreotide (block glucagon’s peripheral vasodilatory effects).
How are the liver, the kidneys, and IgA nephropathy related?
The failing liver does not break down excess IgA in circulation. IgA goes to kidneys and deposits in BM–> IgA nephropathy.
Explain membranoproliferative glomerulonephritis of hepatitis.
In Hepatitis C infxn, immune complexes are formed and not broken down and deposit in BM of glomeruli–> MPG.
Strong association btwn Hep. C and cryoglobulinemia
