Management of Organ Dysfunction Assosciated with end Stage Liver Disease

Abstract

Patients with cirrhosis and portal hypertension are at an increased risk of the development of circulatory dysfunction that may potentially result in multiple organ failure. The pathophysiology of this cirrhotic multiorgan syndrome is due to portal hypertension that may leed to portosystemic shunt and increased hepatocellular dysfunction that may lead to increased circulating levels of vasodilators, which may induce splanchnic vasodilatation and reduced systemic vascular resistance. The translocation of bacterial products from the gut may further augment the splanchnic and arterial vasodilatation that leads to a number of hemodynamic changes and, ultimately, to a universal hyperdynamic syndrome. This hyperdynamic syndrome affects many organ systems such as the heart leeding to cirrhotic cardiomyopathy, the lungs leading to hepatopulmonary syndrome, the kidneys leading to hepatorenal syndrome, and the brain leading to hepatic encephalopathy. Hepatorenal syndrome (HRS) is defined as renal failure that occurs in the presence of severe acute or chronic liver disease in the absence of underlying renal pathology. HRS diagnosis is determined based on positive criteria associated with excluding other causes of renal failure in patients with liver cirrhosis and ascites. The therapies such as vasoconstrictor drugs or transjugular intrahepatic portosystemic shunt are effective methods in the renal function improvement. Hepatopulmonary syndrome (HPS) is a pulmonary complication of liver disease characterized by arterial hypoxemia. It is distinguished by three specific clinical entities consisting of liver disease and/or portal hypertension, disturbance of alveolar-arterial oxygen gradient, and intrapulmonary vascular dilatations. Despite years of research, diagnosing HPS is still difficult due to the existence of other comorbidities and unclear clinical presentation. Moreover, the only proven therapy for HPS is liver transplantation (LT). Thus, early diagnosis of HPS is needed to put the patients in priority list for LT. Hepatic encephalopathy (HE) is a neuropsychiatric disorder seen in patients with advanced liver disease or porto-systemic shunts. Ammonia is believed to play crucial role in pathogenesis of HE via astrocyte swelling and cerebral edema. But other factors such as inflammation, neurosteroids and manganese are also implicated in the development of the disease. The diagnosis remains largel