RRI as Diagnostic and Follow up Indicator in Cirrhosis of the Liver with Hepatorenal Syndrome and Refractory Ascites.

Introduction: Hepatorenal syndrome (HRS) is a syndrome of functional renal failure occurring in patients with advanced liver failure in the absence of clinical, laboratory, or histological evidence of other known causes of renal failure. However HRS has always been considered to be potentially reversible. RRI (Renal Resistive Index) is an affordable, non invasive and easily available tool which can be used to detect the early onset of HRS. Large volume paracentesis and albumin infusion along with splanchnic vasoconstrictors are the mainstay in the treatment of refractory ascites. The cost of treatment with terlipresin is prohibitive for people in the rural areas but not so with noradrenaline. Therefore, noradrenaline should be an acceptable alternative, in a developing country, especially in Rural India.

Aim: The aims of this study were to determine the usefulness of RRI in diagnosis and follow up of HRS and to determine if large volume paracentesis with noradrenaline and albumin infusion can prevent patients from going into Hepatorenal syndrome.

Materials And Methods: Type of study: Prospective Observational clinical study. Dept. Of Medicine MVJ MCand RH Hoskote. Patients with cirrhosis of liver, refractory asites and an RRI of > 0.70 were included in the study. A protocol for LVP (Large volume paracentesis) was laid down and followed in each case. Follow up RRI was done on 2nd day, 7th day and after two months.

Results: 184 patients with cirrhosis of liver with tense ascites underwent RRI by USG Doppler. 53 patients with RRI of > 0.7 were included in the study, after fulfilling the inclusion and exclusion criteria of which 25 patients (Cases) gave informed consent; the remaining 28 who were not willing for LVP were considered as "controls". The mean RRI of cases was 0.7617+ 0.0457; the follow up mean RRI of cases on the 2nd day, 7th day and after 2 months were 0.6821+0.0466, 0.6375+0.0311 and 0.6030 +0.0461 respectively, with the p value of 0.00001. In the control group the mean RRI was 0.7245+0.0174 and the follow up mean RRI on the 2nd day, 7th day and after 2 months were 0.7245+0.174, 0.7191+0.0148 and 0.7368+0.01944 respectively, with the p value of 0.2100.

Conclusion: RRI is an affordable, non invasive and easily available tool which can be included as part of a routine Ultrasonographic evaluation in liver cirrhotics. The RRI can be used for assessing early onset of HRS and in follow up. Large volume paracentesis, Noradrenaline with Albumin infusion (5 gms/litre of ascitic fluid removed) is as effective as other costlier options for refractory ascitis.