Pathophysiology- Chronic Liver Failure 2 Flashcards
what are some of the proposed mechanisms of hepatic encephalopathy?
- ammonia, nitrogenous wastes
- increased intracellular glutamine
- astrocyte swelling, cerebral edema
- inflammatory cytokines alter blood-brain barrier
who notices changes in mental status for chronic hepatic encephalopathy?
- often by family members but missed by coworkers or physicians
- slow and subtle onset
what PE findings do you see with hepatic encephalopathy?
- asterixis- hyperextended wrists with flapping movement, inability to perform the sustained grip of the hand
- myoclonus- hyperextension of the ankle
- absence of sensory, motor, or cerebellar deficit to suggest another etiology for altered mentation
is chronic hepatic encephalopathy reversible?
- yes generally reversible with treatment
- w/ long standing chronic hep encephalopathy–> permanent brain damage can occur
- mild decrease in mentation, calculations
how do you treat chronic hepatitis encephalopathy?
- treat the precipitating conditions like hypovolemia, hypokalemia, gi bleed, meds, exclude intracranial hemorrhage
what is lactulose?
- poorly absorbable sugar
- cathartic
- decrease intestinal ph
- decrease glutamine absorption
- reduce syntehsis and absorption of nh3
what is zinc sulfate?
- cofactor in NH3 metabolism
- zinc deficiency is common in liver disease
- correction of zinc is part of tx of excephalopathy
what do antibiotics do in terms of liver and gut
- alter intestinal flora
- decrease NH3
- decrease intestinal mucosal glutaminase
- decrease coliform bacteria which produce urease and convert urea to NH3
how to treat chronic liver failure?
- nutrition
- skeletal muscle metabolizes NH3. malnutrition is common in liver patients. Protein restriction is not helpful.
- High veggie proteins with increased branched chain AA advised
what are some renal complications associated with liver disease?
- hepatorenal syndrome
- iga nephropathy
- membranoproliferative glomerulonephritis
- membranous glomerulonephritis
what is hepatorenal syndrome
- liver failure cuase renal arterial vasoconstriction and renal failure
- not associated with renal parenchymal abnormality
- genreally reversed with correction of liver failure such as with transplantation
how to diagnose hepatorenal syndrome?
- cirrhosis and ascites
- no recent nephrotoxic drugs
- no underlying renal disease ( >500mg protein/day, >50 RBCs/hpf), no improvement,
- serum creatinine >1.5
how do you diagnose hepatorenal syndrome?
- exclusion of other etiologies
- lack of return of renal function with intravascular volume repletion
whats the difference between type 1 and type 2 hepatorenal syndrome?
- type 1 is rapidly worsening or decrease in CrCl <20 ml/min within 2 weeks
- type 2 is slow progression, often with worsening liver disease
tx or hepatorenal syndrome?
- liver transplantation
- hemodialysis until liver transplantation
what is the most common cause of IgA nephropathy?
liver disease
what is IgA nephropathy?
- increased deposition of IgA, c3, and other immunoglobulins in 35-90% of cirrhosis patients
- decreased hepatic clearance of IgA with cirrhosis and portal hypertension(with collateral blood flow around the liver)
what is membranoproliferative glomerulonephritis associated with?
- chronic hep c
- immune complex formation with chronic hep c
- cryoglobulinemia- abnormal protein in the blood which precipitates with cold temp
what is membranous glomerulonephritis associated with?
hep c and b
