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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$entrations
Severe Rise in %las#a
Renin, Aldosterone,Noreinehrine and
*asoressin Con$entrations
E9tre#e Elevation of %las#a
Renin, Aldosterone,Noreinehrine and
*asoressin Con$entrations
Moderate Renal *aso$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$terialis %eritonitis 1SB%2
Gines & Arroyo.Gut 2000;46:588-590
"##e$t o" Albumin in Cirrhosis with Ascites
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2. In the prevention of renaldysfunction2
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
-
"##e$t o" Albumin in Cirrhosis with Ascites
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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$tivity (ng*'l.+),enal #ailure*Hyponatre'ia
p/ p0.01p0.01
Gines et al, Gastroenterolo!" 3@
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2. In the prevention of renaldysfunction3
"1P: Sontaneous infe$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
"##e$t o" Albumin in Cirrhosis with Ascites
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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$le,s(in, and brain
Gines & Arroyo.Gut 2000;46:588-590
,ole o" Albumin in Cirrhosis with Ascites
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In the treatment of Hepato-Renal
Syndrome2
8R": %las#a volu#e e9ansion ith
Albu#in or %eritoneovenous shuntin! or
vaso$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*