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Summary of the Day

Pediatric Flexible Endoscopic Intubation

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Question of the Day

A 58-year-old man with alcoholic cirrhosis presents for liver transplantation. His serum creatinine is 1.7 mg/dL, his blood pressure is 90/45 mmHg, and he has ascites, which has been refractory to repeated large volume paracentesis. Which of the following complications is he MOST at risk for related to his end-stage liver disease?

Question of the Day
A 58-year-old man with alcoholic cirrhosis presents for liver transplantation. His serum creatinine is 1.7 mg/dL, his blood pressure is 90/45 mmHg, and he has ascites, which has been refractory to repeated large volume paracentesis. Which of the following complications is he MOST at risk for related to his end-stage liver disease?
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Explanation

Hepatorenal syndrome (HRS) is a syndrome of renal insufficiency that occurs in patients with end-stage liver disease who have refractory ascites and low blood pressure and is thought to be a result of increased cardiac output, systemic vasodilation and effective hypovolemia. These changes over time lead to increased splanchnic vasodilation but also an increase in catecholamines which stimulates renal vasoconstriction through the renin-angiotensin-aldosterone system. This prerenal state with hypoperfusion causes the kidneys to retain salt and water which further worsens ascites. There are two types of HRS. Type 1 HRS is rapidly progressive associated with multisystem organ failure and very high mortality. The only treatment is liver transplantation. Type 2 HRS is more slowly progressive with refractory ascites and a reduced median survival time at 6 months, and can be treated with transjugular intrahepatic portosystemic shunt placement. Other initial treatments for HRS include albumin infusion and vasoconstrictor medications such as vasopressin analogues, midodrine, octreotide and norepinephrine.

OA Series: April 2024

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REPOST: October 2021 – Pediatric Tracheal Extubations

Debnath Chatterjee, MD, FAAP, Children’s Hospital Colorado