The ‘Hepatorenal’ Syndrome and Refractory Ascites

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Abstract
The charts of 30 consecutive patients who underwent implantation of a LeVeen type of peritoneal-venous (P-V) shunt were reviewed. Patients [29] 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 Na (UNa) and no other apparent cause for renal failure. In these patients with plasma creatinine (pCr) > 1.6 mg/dl and BU[blood urea]N > 30 mg/dl and UNa < 10 meq/l, the P-V shunt significantly 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/l. Of these patients, 4 are still alive a mean of 418 days after being shunted (preshunt BUN = 60 mg/dl). Three 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 Na clearance (CNa) and fraction of the filtered Na being excreted CNa/Ccr [creatine clearance]. In patients studied while off diuretics the CNa/Ccr increased after shunting from 0.21 to 1.45% (P < 0.025). The avid renal salt adsorption characteristic of refractory ascites and HRS was apparently reversed. The P-V shunt may be beneficial therapy, especially in preterminal HRS, and may function in a physiologic manner, by decreasing the renal reabsorption of Na and water.

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