Albumin in Liver cirrhosis, SA.ppt

8/9/2019 Albumin in Liver cirrhosis, SA.ppt

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Is there still a need for

HSA ABDURACHMAN

Sub-Div. Gastro-Entero-Heatolo!"Deart#ent of Internal Medi$ine

%ad&ad&aran Universit" 'a$ult" of Medi$ineDr Hasan Sadi(in Hosital

BANDUNG$


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)I*ER CIRRH+SIS

Chroni$, diffuse ro$ess

Conversion of nor#al liver ar$hite$ture

Stru$turall" abnor#al nodules

Multile $auses

Initiall" develo ithout s"#to#s si!ns

Pro!ress/ - %ortal H"ertension

- )iver 'ailure


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C+M%)ICA0I+NS +' )I*ER CIRRH+SIS

As$ites and Ede#a

- Heato-Renal S"ndro#e 1HRS2

- Sontaneous Ba$terial %eritonitis 1SB%2

%ortal h"ertensive bleedin!

Heati$ En$ehaloath"

34 "rs/ De$o#ensated in 546

Survival rate 746


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'AC0+RS IN*+)*ED in the %A0H+GENESIS of

RENA) D8S'UNC0I+N and ASCI0ES '+RMA0I+N in

CIRRH+SIS

Renin-An!iotensin-Aldosterone S"ste#

S"#atheti$ Nervous S"ste#

Atrial Natriureti$ %etide

Ara$hidoni$ A$id Metabolites

Nitri$ +9ide

Endothelin

Carbon Mono9ide


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MAR:ED CIRCU)A0+R8 D8S'UNC0I+N in

CIRRH+SIS and ASCI0ES

)o s"ste#i$ vas$ular resistan$e

)o arterial ressure

Abnor#al blood volu#e distribution

Redu$ed $entral blood volu#e

Mar(ed sti#ulation of vaso$onstri$tors and antinatriureti$

s"ste# 1RAA and SNS2

Intense $ir$ulator" d"sfun$tion renal erfusion ; fun$tion

is !reatl" redu$ed/ HRS

A)BUMIN IN'USI+NS in CIRRH+SIS and ASCI0ES/

atte#t to redu$e the for#ation of as$ites and ; or

i#rove $ir$ulator" and renal fun$tion


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ASCI0ES AS C+M%)ICA0I+NS +' )I*ER

CIRRH+SIS

Grade 3

- Clini$all" silent- Dete$table onl" b" USG

Grade


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A)BUMIN USE> 132

In A$ute Chroni$ illness/

Seru# albu#in inversel" related to ris( of death

'or ea$h


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A)BUMIN USE> 1


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Albumin Use?1=2

Guidelines for the use of Albu#in are toaid ra$titioners/

sul",safet",$ost $on$ern,aroriate indi$ations and effi$ient use

Should be eviden$e-based Develoed usin! a $onsensus aroa$h of

#edi$al e9erts

Coo(. Current 0oi$s. an


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Albumin Use?1?2

If based on $lini$al e9erien$eand have notbeen roved in rose$tive investi!ations/

Use of Albu#in infusions is $ontroversial Debate fostered b" the hi!h $ost and

li#ited availabilit"

Inaroriate indi$ationsin )iver Cirrhosis/nutritional sule#entation

&ust h"oalbu#ine#ia

in$reasin! dru! effi$a$"lo volu#e ara$entesis

Coo(. Current 0oi$s. an


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USED of A)BUMIN in

CIRRH+SIS IS C+N0R+*ERSIA)

So#e of albu#in indi$ations/ suorted b" results of RC0s

based onl" on $lini$al e9erien$e and have not been rovedin rose$tive investi!ations

Hi!h $ost and li#ited availabilit" of albu#in

Meta anal"sis on albu#in infusions in $riti$all" ill atients/#a" in$rease #ortalit"


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AR0ERIA) *AS+DI)A0A0I+N H8%H+0ESIS

Co#ensated Cirrhosis De$o#ensated Heatorenal S"ndro#e

Moderate PeripheralVasodilation (eg splanchnic!

"evere ParipheralVasodilation

#$tre%e Peripheralvasodilation

Moderate De$rease Effe$tive

Arterial Blood *olu#e 1EAB*2

Severe De$rease

EAB*

E9tre#e De$rease

In EAB* ith H"otension

Moderate in$rease %las#a

Renin, Aldosterone,Noreinehrine and

*asoressin Con$entrations

Severe Rise in %las#a



E9tre#e Elevation of %las#a



Moderate Renal *aso$onstri$tion

Fith Renal Sodiu#

And Fater Retention

Severe Renal *aso$onstri$tion

Fith Renal Sodiu#

And Fater Retention

E9tre#e Renal *aso$onstri$tion

Fith Renal Sodiu# And

Fater RetentionR#&'L

')LLUR#

%las#a *olu#e E9ansion %las#a *olu#e E9ansion

#a" be #odifled b" h"oalbu#ine#ia

%las#a *olu#e E9ansion

#a" be #odifled b" h"oalbu#ine#ia

Return of las#a Renin

Aldosterone, Noreinehrine

and *asoressin Con$entrations

0o Nor#al *alue

Inadeuate to Nor#allJe

Renal He#od"na#i$s

%las#a Renin, Aldosterone

Noreinehrine and

*assoresin Con$entrations

%las#a Renin, Aldosterone

Noreinehrine and *asoressin

Con$entrations Re#ain hi!h levels

'scites or%ation urther 'scites or%ationGines, Arro"o, Rodes, S$hrier/

As$ites and renal d"sfun$tion in


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Cirrhosis with Ascites

M'R*#D C)RCUL'T+R, D,"U&CT)+&/Low systemic vascular resistance, arterial

hypotension, an hi!h cariac output)o s"ste#i$ vas$ular

resistan$e/ due to #ar(ed slan$hni$

vasodilatation as $onseuen$es of in$reased a$tivit" of/

N+, %Gs and vasodilator etides

Abnormal istribution o" bloo volume # $A%&Mar'e stimulation o" vasoconstrictor an

antinatriuretic systems ()AAS, S*S+

Dilutional hyponatremia an renal ys"unctionunfavourable ro!nosis Abel#an FH, Heatolo!" 3@@?


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Ascites shoul be treate

- Survival 746 at < "rs- Diureti$-resistant develo in 346

- Survival in diureti$-resistant/

746 at 5 #os,


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Refractory Ascites

K DIURE0IC-RESIS0AN0 ASCI0ES:As$ites that $annot be #obiliJed or

Earl" re$urren$e of hi$h $annot be revented

due to la$( of resonse to

sodiu# restri$tion and diureti$ thera"

K DIURE0IC-IN0RAC0AB)EASCI0ES/As$ites that $annot be #obiliJed or

Earl" re$urren$e of hi$h $annot be reventeddue to develo#ent of diureti$-indu$ed $o#li$ationsthat re$lude use of effe$tive dosa!e

International As$ites Club,3@@5


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Diuretic.resistant LiverCirrhosis

Inabilit" to #obiliJe as$ites desite Na restri$tionand #a9i#u# oral diureti$s 1354 #! furose#idelus ?44 #! sironola$tone2

Develo#ent of aJote#ia, heati$ en$ehaloath",ro!ressive ele$trol"te i#balan$e

Large Volu%e Paracentesis

re#ove ? L 5 ) as$ites;d in $on&un$tion ith ivalbu#in 5- !;) as$ites re#oved

Arro"o ea. Heatolo!" 3@@5/


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1. In the management of circulatory

and renal dysfunction Durin! ?4s L 54s/

Albu#in to redu$e as$ites for#ation

As$ites did not de$rease desite in$reased seru# albu#in

and nor#al on$oti$ ressure

Albu#in to i#rove $ir$ulator" and renal fun$tion/

In$reased total blood volu#e, redu$tion of vaso$onstri$torsand RAAS/ +nl" in )C ith sli!htl" i#airedrenal fun$tion

In severe renal d"sfun$tion/ albu#in lus vaso$onstri$tors

Gines & Arroyo.Gut 2000;46:588-590

"##e$t o" Albumin in Cirrhosis withAscites


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2. In the prevention of renaldysfunction1

Deterioration of i#aired $ir$ulator" d"sfun$tion

due to/ )ar!e *olu#e %ara$entesis 1)*%2

Sonteous Ba$terialis %eritonitis 1SB%2


"##e$t o" Albumin in Cirrhosis with Ascites


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LVP #arl- favoura.le he%od-na%ic effect due to: Suression of vaso$onstri$tor and natriureti$ fa$tors

In$reased las#a natriureti$ etide

Post Paracentesis circulator- d-sfunction: I#air#ent of EAB*/ Mar(ed a$tivation of vaso$onstri$torand natriureti$ fa$tors

hile las#a volu#e un$han!ed

Not sontaneousl" reversible

I#air#ent of renal fun$tion and dilutional h"onatre#ia

De$reased survival

Prevented successfull- .-'l.u%in /g0l ascites re%oved'l.u%in plus vasoconstrictor

Gines ea.Gastroent. 1988;84:149!-1502Gines & Arroyo.Gut 2000;46:588-590

-



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Paracentesis.Inuce CirculatoryDys"unction

$/ects on Plasma &olume an )AAS

0

1000

2000

3000

4000

Before After0

10

20

30

40

Before After

las'a volu'e ('l) las'a renin a$tivity (ng*'l*+)

Salo et al, Heatol 3@@


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aracentesis Inuce Circulatory Dys"unctionAlbumin vs no Albumin

BA

B

A

0

4

8

12

Albumin No Alb

0

5

10

15

20

Albumin No Alb

las'a ,enin A$tivity (ng*'l.+),enal #ailure*Hyponatre'ia

p/ p0.01p0.01

Gines et al, Gastroenterolo!" 3@


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"1P: Sontaneous infe$tion of as$ites due to assa!e of

intestinal ba$teria

Chan!es in $ir$ulator" fun$tion renal failure in 3;= ts Due to hi!h level of $"to(ines and vasodilator fa$tors in las#a

and as$iti$ fluid

I#aired ro!nosis

#ffective prevented .- anti.iotic treat%ent co%.ined 2ith'l.u%in: 34 g0kg15 at da- 3 3 g0kg15 da-s 6 and 7

/ort ea. "n l %e.1999 !41:40!-510



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In the treatment of Hepato-Renal

Syndrome1

8R": E9tre#e e9ression of $ir$ulator" d"sfun$tion in

$irrhosis ith as$ites

*er" lo arterial ressure and total s"ste#i$vas$ular resistan$e

Mar(ed overa$tivit" of RAAS, SNS, ADH andendothelin

Mar(ed arterial vaso$onstri$tion in (idne", #us$le,s(in, and brain


,ole o" Albumin in Cirrhosis with Ascites


24/37

In the treatment of Hepato-Renal

Syndrome2

8R": %las#a volu#e e9ansion ith

Albu#in or %eritoneovenous shuntin! or

vaso$onstri$tors/ little su$$essMar(ed i#rove#ent after $o#binationtreat#ent of

vaso$onstri$tor 1orniressin, #idodrine, o$teotride2and Albu#in for several da"s;ee(s

Interi# treat#ent of HRS reared for liver translantation

Guevara ea.Hepatology;1998;2:!5-41

An eli ea.He atolo .1999 29:1690-169

,ole o" Albumin in Cirrhosis with Ascites


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Concl. Use of l!umin in "C 1eneficial effect of 'l.u%in:

#odest and li#ited onl" to )C ith sli!htl" i#aired renal fun$tion

ho resond to $onventional treat#ent/ $lini$all" not relevan$e to

&ustif" su$h thera" in #ost of )C ith as$ites

'l.u%in in LC 2ith diuretic9resistant acsites:

$ould revent renal i#air#ent b" #aintainin! EAB*

'l.u%in in LC 2ith diuretic9resistant ascites:

ver" effe$tive in reventin! renal fun$tion deterioration due to )*%

and SB% i#rove survival in SB%

)n i%proving renal function in 8R" 2ith

esta.lished circulator- d-sfunction: Albu#in alone is not effe$tive

Albu#in lus slan$hni$ vaso$onstri$tors


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00+NSENSUS+NSENSUS

PPENGGUNAANENGGUNAAN AA)BUMIN)BUMIN PPADAADASSIR+SISIR+SIS 11A0IA0I

%%HI-%GI-%EGI%%HI-%GI-%EGI

6 ; 6< 'pril 6==7&ikko 8otel> Denpasar> 1ali


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IINDI:ASINDI:ASI PPEMBERIANEMBERIAN AA)BUMIN)BUMIN

-SB% BERA0

-1RS 08%E 3

-Seba!ai en!e#ban! las#a sesudahara$entesis volu#e besar 1 O 7 liter2

-0adar albu#in P


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CCARA PPEMBERIAN LLAR. AA)BUMIN- ##ecepatan infus:ecepatan infus:

- Albu#in


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PPEMAN0AUANEMAN0AUAN

- SStatus he%odina%iktatus he%odina%ikL 0anda vital 1te(anan darah, nadi, resirasi, C*%20anda vital 1te(anan darah, nadi, resirasi, C*%2

L Ira#a &antun!Ira#a &antun!

L 'oto tora(s'oto tora(s

- SStatus koagulasitatus koagulasi- SStatus gin@altatus gin@al

L %rodu(si urin, ureu# - (reatinin%rodu(si urin, ureu# - (reatinin

L Ele(trolitEle(trolit- ##adar al.u%in seru% diperiksa 6A ; A/ @a%adar al.u%in seru% diperiksa 6A ; A/ @a%- $$e%antauan disesuaikan dengan kondisi ru%ah sakite%antauan disesuaikan dengan kondisi ru%ah sakit

sete%patsete%pat


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$$'E:'E:SSAM%INGAM%ING

- DDe(o#ensasi &antun!e(o#ensasi &antun!- $$de#a arude#a aru

- ))isi(o erdarahan - erdarahan varisesisi(o erdarahan - erdarahan varises

- PPenu#u(anenu#u(an nitrogen bodiesnitrogen bodies- AA(u#ulasi obat, #etal, hor#on di ruan! interstisial(u#ulasi obat, #etal, hor#on di ruan! interstisial

- %%ersifat anti(oa!ulan, #en!ha#bat a!re!asi tro#bositersifat anti(oa!ulan, #en!ha#bat a!re!asi tro#bosit

dan antitro#bin IIIdan antitro#bin III- 11io(alse#iaio(alse#ia

- ))ea(si transfusi> 0er$e#ar virus heat resistant>ea(si transfusi> 0er$e#ar virus heat resistant>


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Serum Albumin/

Predo#inant seru#-bindin! rotein

Co#rises/

76 L 46 of nor#al las#a $olloid on$oti$ressure and 546 of rotein $ontent

Seru# values =.7 L ?.7 !;l2otal bod" $ontent =44 L 744 !

S"nthesis in heati$ $ells onl" / @ - 3< ! ; d

1alf-life


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1ypoalbuminemia maybe ue to

De$reased albu#in rodu$tion

Defe$tive s"nthesis due to heato$"te da#a!e Defi$ient inta(e of a#ino a$ids

In$reased losses of albu#in via disease

Stress-indu$ed $atabolis# of bod" rotein

1e#odilution


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Liver Cirrhosis

K 2

K i#aired di!estion absortion of

nutrients

K redu$ed rotein s"nthesis

Moria(i et al,


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Dietary Mana!ement Problemin Liver Cirrhosis

Catabolis# durin! ro!ression of the disease

I#aired rotein #etabolis#

AAA %CAA 1"erinsulinis# and Insulin resistan$e

346 L =46 DM in )iver Cirrhosis

Protein 1and $alorie2 defi$ien$"

Intoleran$e to oral rotein inta(e/ indu$eHeati$ En$ehaloath"

$%R&"


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$%R&"H'$(R&()SI%)

S%)ANCHNIC AR0ERIA)

*AS+DI)A0A0I+N

AR0ERIA) H8%+0ENSI+NAR0ERIA) H8%+0ENSI+N

HIGH %RESSURE BAR+RECE%0+R

MEDIA0ED AC0I*A0I+N +' 0HE

RAAS. SNS

HIGH %RESSURE BAR+RECE%0+R

MEDIA0ED AC0I*A0I+N +' 0HE

RAAS. SNS

*AS+C+NS0RIC0I+N IN RENA)

CIRCU)A0I+N IN +0HER N+N S%)ANCHNIC

CIRCU)A0I+N

*AS+C+NS0RIC0I+N IN RENA)

CIRCU)A0I+N IN +0HER N+N S%)ANCHNIC

CIRCU)A0I+N

IM%AIRED 'REE FA0ER ECRE0I+NIM%AIRED 'REE FA0ER ECRE0I+N

S+DIUM AND FA0ER RE0EN0I+NS+DIUM AND FA0ER RE0EN0I+N

S$hrier ea.Heatolo!" 3@/3373-337

UNDER'I))ING 0HE+R8

$%R&"


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$%R&"H'$(R&()SI%)

B+R5'RD )&CR#'"# +

"PL'&C8&)C C'P)L'R,

PR#""UR# '&D P#RM#'1)L)T,

B+R5'RD )&CR#'"# +

"PL'&C8&)C C'P)L'R,

PR#""UR# '&D P#RM#'1)L)T,

)8M%H '+RMA0I+N

)8M%H RE0URN

'T#R)'L V'"CUL'R

U&D#R)LL)& '&D 'CT)V'T)+&

"+D)UM R#T')&)& M#C8'&)"M

'T#R)'L V'"CUL'R

U&D#R)LL)& '&D 'CT)V'T)+&

"+D)UM R#T')&)& M#C8'&)"M

S+DIUM AND FA0ER

RE0EN0I+N

ASCITESASCITES

+R5'RD T8#+R,SPLA*C1*IC A)2$)IAL

&AS9DILA2A2I9*

Albumin in Liver cirrhosis, SA.ppt

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