Diagnostic value of Doppler examination in hepatorenal syndrome
Background. Alcoholic liver cirrhosis (ALC) is often complicated by hepatorenal syndrome (HRS), in which pathophysiological changes in kidneys are considered to be dependent with other organs, including the liver, but there is a very limited number of studies with concurrent evaluation of renal and hepatic blood flow by means of Doppler method, depending on the stage of severity in such patients. The aim of our study was to determine and compare the changes of Doppler ultrasound parameters of hepatic and renal blood flow in patients with alcoholic cirrhosis, depending on the stage of the disease, and to assess the relationship of these indicators with surrogate markers of renal function. Materials and methods. The study enrolled 152 patients. ALC was diagnosed antemortem by laboratory tests and imaging methods, at autopsy — on the basis of macro- and micromorphological features in a view of clinical data. All patients were divided into 3 groups according to the stage of the disease by CLIF-ACLF scale and MELD scale: group 1 — CLIF-ACLF-I (MELD < 15) (n = 42), group 2 — CLIF-ACLF-II (MELD < 20) (n = 58), group 3 — CLIF-ACLF-III (MELD > 20) (n = 52). Doppler indices of hepatic and renal blood flow were studied. Results. Clinical characteristics of the patients: the average age of patients at the time of inclusion in the study was (42.34 ± 12.57) years; the average duration of ALC — (3.50 ± 1.54) years; the average length of alcohol abuse (being registered at the Regional Drug Dispensary) — (8.42 ± 3.53) years; gender distribution: 79.6 % (n = 121) — males, 20.4 % (n = 31) — females (p < 0.05). Among all enrolled patients, only 52 had score by MELD > 20, which corresponds to a high risk of mortality over the next 3 months in 19.6 % of them. According to the CLIF-ACLF scale, all these patients had the third stage. MELD score < 20 corresponded to the I–II stage by CLIF-ACLF scale. Among all Doppler indices, only portal blood flow demonstrated the significant differences by the stages of CLIF-ACLF scale, arterial hepatic blood flow didn’t change significantly. Patients of group 3 had a significant reduction of TAMH PV, Vmax PV, QPV, PSVI, reduced PSI and mPSI, but increased CI, which may be explained by the formation of hypokinetic type of liver hemodynamics. It was also found a strong correlation between the stage by CLIF-ACLF scale and Vmin, RI and PI of the left and right renal arteries (RA). We revealed the correlation between the values of Doppler parameters and indicators by MELD scale. Significant reduction of Vmean, Vmin in the right and left RA, and increase in RI and PI in right and left RA was observed in patients with MELD index < 20, compared with those, who had MELD > 20 and stage III by CLIF-ACLF scale. Only Vmax values of the right and left RA had no statistically significant changes. In patients with esophageal varices, we observed a decreased Vmean of the right RA (p = 0.02) and left RA (p = 0.038), reduced Vmax of the right RA (p = 0.045), and decreased Vmin of the right RA (p = 0.003) and left RA (p = 0.025) as compared to rates in those without esophageal varices. When comparing patients of groups 1–2 with patients of group 3, we noticed a significant reduction of Vmin in right RA (p = 0.021) and increased RI in the right RA (p = 0.020) and left RA (p = 0.028), increased PI in the right RA (p = 0.024) and left RA (p = 0.002). Vmean in the right and left RA (p = 0.015) and Vmin in the right RA (p = 0.027) were also reduced in patients with ascites, as compared to those without it. We observed a correlation between the Doppler indices in the arteria hepatica communis and hepatic arterial index on the one hand, and indicators of renal blood flow — on the other. Conclusions. The results of our studies showed that in patients with alcoholic liver cirrhosis, hepatic and renal blood flow undergo the parallel changes, especially depending on the stage of the disease by CLIF-ACLF scale and on the patient’s age. We found no direct correlation between the kinds of alcoholic liver cirrhosis complications and most indicators of hepatic blood flow. In contrast, renal doppler parameters correlate with the severity of liver cirrhosis and the presence of its complications. Due to the significant changes in renal blood flow parameters as the progression of cirrhosis, we can recommend doppler ultrasound of the renal arteries as part of a comprehensive observation of patients in the dynamics, especially for predicting the short-term mortality and for stratification of severity of the disease.
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