syndrome hepatorenal s anesthesie reanimation 1 p … · 2008-04-05 · 0 250 500 j0 j1 j2 j3 j4 j5...
TRANSCRIPT
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SERVICE D’ANESTHESIE REANIMATION 1P SEGUIN
SYNDROME HEPATORENAL
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- PATIENT de 56 ans.
- MALADIE HEPATIQUE:
Cirrhose éthylique évoluant depuis 3 ans.=> DECOMPENSATION OEDEMATO ASCITIQUE (DOA) INAUGURALE. HTp avec VO STADE I-IIDEPUIS :
- 3 DOA dans les 6 mois précédents.- VO stade III.- Sevrage en alcool incomplet.= > Child-Pugh B9
- TRAITEMENT ACTUEL :Aldactone - Furosémide
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Nlle DOAFièvre 39°CGB 15800/mm3
J0
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Nlle DOAFièvre 39°CGB 15800/mm3
J0
- Ponction asciteévacuatrice (8L)- Hémocultures
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J0
GB 860/mm3
ED BGNCult E. coli
CEFOTAXIME4g/j
J4J2
Nlle DOAFièvre 39°CGB 15800/mm3
J0
- Ponction asciteévacuatrice (8L)- Hémocultures
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0
250
500
J0 J1 J2 J3 J4 J5 J6 J7 J8
0
250
500
750
1000
J0
GB 860/mm3
ED BGNCult E. coli
CEFOTAXIME4g/j
J4
GB 100/mm3
ED (-)Cult(-)
OLIGURIE (500 mL/j)IRA CREATININE 180 µmoL/L
J6J2 J8
Créatinine (µmol/l)
Diurèse (mL)
Nlle DOAFièvre 39°CGB 15800/mm3
J0
- Ponction asciteévacuatrice (8L)- Hémocultures
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INSUFFISANCE RENALE AIGUË423 PATIENTS
32%33%
SD HEPATORENALI = 85 - II = 28
27%
GASTROENTEROLOGY 2002; 122:923
REMPLISSAGE
- +
INSUFFISANCE RENALEFONCTIONNELLE
CHOC SEPTIQUEou
HEMORRAGIQUE
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CHOC SEPTIQUEou
HEMORRAGIQUE
INSUFFISANCE RENALE AIGUË423 PATIENTS
32%33%
SD HEPATORENALI = 85 - II = 28
27%
GASTROENTEROLOGY 2002; 122:923
REMPLISSAGE
- +
Insuffisance rénale“fonctionnelle
6%
UROPATHIE
GLOMERULOPATHIE
TOXICITEMEDICAMENTEUSE
1,8%
0,2%
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POSE CATHETER VEINEUX CENTRAL
ARRÊT DIURETIQUES
PVC 4 cm H2O => REMPLISSAGE
PROTEINURIE - HEMATURIE
1000mL COLLOIDESPVC 10 cm H2O
BANDELETTE URINAIRE -
ECHOGRAPHIE RENALE NORMALE
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POSE CATHETER VEINEUX CENTRAL
ARRÊT DIURETIQUES
PVC 4 cm H2O => REMPLISSAGE
PROTEINURIE - HEMATURIE
1000mL colloïdesPVC 10 cm H2O
BANDELETTE URINAIRE -
ECHOGRAPHIE RENALE NORMALE
SYNDROME
HEPATORENAL
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0,1
0,2
0,3
1 2 3 4 5
0,4
0,518% 39%
ANNEES
GASTROENTEROLOGY 1993; 105:229
COURS EVOLUTIF CIRRHOSE
PROBABILITESHR %
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CRITERES DIAGNOSTIQUES
- CIRRHOSE avec ASCITE
- CREATINEMIE > 133 µmol / l - PAS de CHOC- PAS de MEDICAMENT NEPHROTOXIQUE- INSENSIBILITE AU REMPLISSAGE VASCULAIRE
ALBUMINE 1g/kg - MAX 100 g/j
- PAS de NEPHROPATHIE
GUT 2007; 56: 1310
1978 - MODIFIER 1996
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PRONOSTIC SYNDROME HEPATORENAL
REGRESSION SPONTANEE < 5%
PROBABILITE DE SURVIE 1 MOIS = 25%
MEDIANE DE SURVIE < 2 SEMAINES
GASTROENTEROLOGY 1993;105:229
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DEUX TYPES SYNDROME HEPATORENAL
SHR type I
INSTALLATION RAPIDE
FACTEURS PRECIPITANTS
INSUFFISANCE RENALE ++
SHR type II
INSTALLATION PLUS LENTE
FACTEURS PRECIPITANTS
INSUFFISANCE RENALE +
CHRONIQUEAIGUË
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DEUX TYPES SYNDROME HEPATORENAL
SHR type I
INSTALLATION RAPIDE
FACTEURS PRECIPITANTS
INSUFFISANCE RENALE ++
SHR type II
INSTALLATION RAPIDE
FACTEURS PRECIPITANTS
INSUFFISANCE RENALE +
CHRONIQUEAIGUË
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FACTEURS DECLENCHANTS
INFECTION BACTERIENNE
HEPATITE AIGUE
HEMORRAGIE DIGESTIVE
PARACENTESE sans expansion volémique
CHIRURGIE “LOURDE”
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COMPLICATIONS DANS LE MOIS QUI PRECEDE
INFECTION BACTERIENNE 36
HEPATITE ALCOOLIQUE 26
HEMORRAGIE DIGESTIVE 22
PARACENTESE 54
13 P.B.S13 I.U basses
11 bactériémies3 pneumopathies
1 empyème
GASTROENTEROLOGY 2002 ;122 :923
Nombrepatients
SYNDROME HEPATORENAL TYPE I
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SHR type ISHR type II
Ascite réfractaire
Probabilitéde survie
Mois
NEW ENGLAND J MED 2004; 350: 1646
PROBABILITE SURVIE
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PHYSIOPATHOLOGIE
VASODILATATION SPLANCHNIQUE> SYSTEMIQUE
CIRRHOSEHYPERTENSION PORTALE
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5060708090
100
Contrôle Cirrhose
3.04.0
5.06.0
Contrôle Cirrhose
7.0
600800
1000
1200
1400
Contrôle Cirrhose
GASTROENTEROLOGY 1989; 97:1304
PROFIL HEMODYNAMIQUE
PRESSION ARTERIELLEMOYENNE DEBIT CARDIAQUE RESISTANCE VASCULAIRE
SYSTEMIQUE
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PHYSIOPATHOLOGIE
VASODILATATION SPLANCHNIQUE> SYSTEMIQUE
CIRRHOSEHYPERTENSION PORTALE
MECANISMES COMPENSATEURSVASOCONTRICTEURS
VASOCONSTRICTION RENALE
VASODILATATEURSSYSTEMIQUES ET LOCAUX
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PHYSIOPATHOLOGIE
VASOCONSTRICTION RENALE
VASODILATATEURSSYSTEMIQUES ET LOCAUX
INSUFFISANCE RENALE
VASODILATATION SPLANCHNIQUE> SYSTEMIQUE
CIRRHOSEHYPERTENSION PORTALE
MECANISMES COMPENSATEURSVASOCONTRICTEURS
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REPONSE NEURO-HORMONALE
SHR - SHR + SHR
ACTIVITE RENINE 3,1 9,9 17,5
ALDOSTERONE 32 130 202
NORADRENALINE 221 571 965
EVOLUTION DE LA CIRRHOSE
HEPATOLOGY 2005; 42: 439
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In vivo Ex vivo
VASOCONSTRICTION RENALE DU SHR
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VASOCONSTRICTION
SAINS CIRRHOSEASCITE -
CIRRHOSEASCITE +
SAINS CIRRHOSEASCITE -
CIRRHOSEASCITE +
0,45
0,65
0,85
ART CEREBRALE MOY ART RENALE
INDEXRESISTANCE
INDEXRESISTANCE
HEPATOLOGY 1998; 28: 39
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RESISTANCE RENALE
RESISTANCE CEREBRALE
r=0,73p<0,001
HEPATOLOGY 1998; 28: 39
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VASOCONSTRICTION
HEPATOLOGY 1993; 17: 788
VOLONTAIRES CIRRHOSE SAINS ASCITE = 0 ASCITE ASCITE + IR n=12 n=12 n=12 n=8
CREAT 0,9 0,9 0,8 1,7
DFG - 95 85 23
BRAS 55 57 40 25
FEMORAL 353 310 327 213
DEBITSANG[mL/min]
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PROFIL HEMODYNAMIQUE
SHR - SHR + SHR
PAM 88 83 75DEBIT CARDIAQUE 7 6 5RVS 962 1058 1096PAPO 9 9 8
EVOLUTION
HEPATOLOGY 2005; 42: 439
ETUDE LONGITUDINALE EVOLUTION DE PATIENTS CIRRHOTIQUES
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CIRRHOSECOMPENSEE ASCITE ET SHR
DEBITCARDIAQUE
VOLUME SANGUINARTERIEL
VASODILATATIONSPLANCHNIQUE
VOLUME SANGUINARTERIEL
CIRRHOSECOMPENSEE ASCITE ET SHR
DEBITCARDIAQUE
VASODILATATIONSPLANCHNIQUE
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CE QUI EST INEFFICACE..
DOPAMINEPROSTAGLANDINESSHUNT PERITONEO JUGULAIREEPURATION EXTRA RENALEOCTREOTIDEMARS
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MOLECULAR ADSORBENTS RECIRCULATING SYSTEM
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MOLECULAR ADSORBENTS RECIRCULATING SYSTEM
13 PATIENTS SHR TYPE I
8MARS
5HDF
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MOLECULAR ADSORBENTS RECIRCULATING SYSTEM
0
2
4
6
8
10
1 2 3 4 5 6 7
CREAT mg/dl BILIRUBINE mg/dl
MARS HDF MARS HDF
p<0,05 p<0,01
LIVER TRANSPLANTATION 2000; 6: 277
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MOLECULAR ADSORBENTS RECIRCULATING SYSTEM
13 PATIENTS SHR TYPE I
8MARS
5HDF
MORTALITE100%
MORTALITE75%
LIVER TRANSPLANTATION 2000; 6: 277
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CE QUI EST EFFICACE..
TRANSPLANTATION HEPATIQUE
VASOCONTRICTEURS + REMPLISSAGE
TIPS
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TRANSPLANTATION HEPATIQUEOUI MAIS...
PROBLEMES
ETATGENERAL
DISPONIBILITEGREFFONS
MORTALITE
MORBIDITE
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40
60
80
100
1 2 3 4
SURVIE [%]
ANNEES
TRANSPLANTATION 1996; 51: 428
TRANSPLANTATION HEPATIQUE ETSYNDROME HEPATORENAL
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CL CREAT >70 40-69,9 20-39,9 <20 N 12778 4419 1560 504DYSFONCTIONPRIMAIRE [%] 5,9 6,2 10,9 9,7MORTALITE [%]- 30 jours 5,2 7,3 14,0 17,3SURVIE [%]- 1 an 88 81 70 66- 2 ans 82 76 64 59
TRANSPLANTATION HEPATIQUE + INSUFFISANCE RENALE
HEPATOLOGY 2002; 35: 1179-1185
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TRANS. HEP. + INS RENALE TRAITEE
60 SHR
38 CI TRANSPLANTATION
22 TRANSPLANTATION +
21TTT VASOPRESSINE
REPONSE RENALE
+n=16
- n=5
9 TRANSPLANTESVs
TRANSPLANTE NON SHRJ HEPATOL 2004; 40: 140
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TRANS. HEP. + INS RENALE TRAITEE
PROBABILITE SURVIE 3 ANS TAUX CREAT 6 MOIS
0 1 sem 1 mois 3 mois 6 mois
J HEPATOL 2004; 40: 140
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TRANS. HEP. + INS RENALE TRAITEE
PROBABILITE SURVIE 3 ANS TAUX CREAT 6 MOIS
0 1 sem 1 mois 3 mois 6 mois
J HEPATOL 2004; 40: 140
SHR traité SHR = 0 n = 9 n = 27
INFECTIONGRAVE
REJET AIGUE 33% 41%TRANSFUSION PEROP 7 7 1ère SEM 4 3
22% 33%
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VASOCONSTRICTEURS - TIPS
FAIBLESSE DES ETUDES
RETROSPECTIVES – PROSPECTIVES NON CONTROLEES
FAIBLES EFFECTIFS
CRITERES DE JUGEMENTS ??FONCTION RENALEMORTALITE
INTENTION DE TRAITER ??REMPLISSAGE VASCULAIRE
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VASOCONSTRICTEURS
TERLIPRESSINE
MIDODRINE
NORADRENALINE
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MODE D’ACTION
VASODILATATION SPLANCHNIQUE
VASOCONSTRICTION RENALE
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MODE D’ACTION
VASOCONSTRICTION SPLANCHNIQUE
VASODILATATION RENALE
TERLIPRESSINEMIDODRINE
NORADRENALINE
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J HEPATOL 2000; 33: 43
Créatmg/ dl
Jours
9 PATIENTS
TERLIPRESSINE
SYNDROME HEPATO RENALTYPE I (n=6) et II (n=3)
TERLIPRESSINE 0,5 mg/4h
ALBUMINE 1g/kg-> 20 à 40 g/j
+
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TERLIPRESSINE
T0 TRAITEMENTACTIVITE RENINE PLASMATIQUE 23 4ALDOSTERONE 342 89NORADRENALINE 1549 373FACTEUR ATRIAL NATRIURETIQUE 108 158
J HEPATOL 2000; 33: 43
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TERLIPRESSINE
SYNDROME HEPATORENAL TYPE I
TERLIPRESSINE1mg/6h
PLACEBOn=56 n=56
CREAT < 1,5 mg/l ET VIVANTJ14
ALBUMINE
HEPATOLOGY 2006; 44: 694A
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TERLIPRESSINE
SYNDROME HEPATORENAL TYPE I
TERLIPRESSINE1mg/6h
PLACEBO
CREAT < 1,5 mg/l ET VIVANTJ14
ALBUMINE
CREAT < 1,5 mg/l ET VIVANTJ14
TERLIPRESSINE 27% PLACEBO 13%
HEPATOLOGY 2006; 44: 694A
↓ CREAT J0 à J14
TERLIPRESSINE 0,7mg/l PLACEBO 0mg/l
SURVIE J60
TERLIPRESSINE 48% PLACEBO 48%
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DIG DIS SCI 2008; 53: 830
TERLIPRESSINE
52 PATIENTS SHR TYPE I
26TERLIPRESSINE
26
ALBUMINE
ALBUMINE
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52 PATIENTS SHR TYPE I
26TERLIPRESSINE
26
ALBUMINE
ALBUMINE
DIG DIS SCI 2008; 53: 830
TERLIPRESSINE
REPONSE RENALECOMPLETE
80%
REPONSE RENALECOMPLETE
19%
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JOURS
TERLIPRESSINE + ALBUMINE
ALBUMINEPROBABILITE
DE SURVIE [%]
DIG DIS SCI 2008; 53: 830
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ETUDE RETROSPECTIVE – 99 PATIENTS - SHR TYPE I.
Réponse Réponse rénale (+) rénale (-) n=53 n=38
TERLIPRESSINE (mg/j) 3,1 3,4DUREE ADMINISTRATION (j) 12 7ALBUMINE IV (%) 79 68
GASTROENTEROLOGY 2002;122:923
REMPLISSAGE VASCULAIRE ?
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TERLIPRESSINE + REMPLISSAGE VASCULAIRE ?
21 PATIENTSSHR TYPE I (n=16) ET TYPE II (n=5).
TERLIPRESSINE + ALBUMINE TERLIPRESSINE
T0 T0TRAITEMENT TRAITEMENT
CREATmg/l ALBUMINE
1g/kg20-40g/j
TERLIPRESSINE0,5 mg/4h
MAX 2 mg/4h
HEPATOLOGY 2002; 36:941
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TERLIPRESSINE
ANNEE n REPONSE EFFETS IIaires
HSR I / II RENALE + ISCHEMIQUES
NERI 2008 52/0 80%SANYAL 2006 56/0 34% -SOLANKI 2003 24/0 - 0%ORTEGA 2002 16/5 57% 5%MOREAU 2002 99/0 63% 5%HALIMI 2002 16/2 72% 16% (ivse)
URIZ 2000 6/3 77% 0%MULKAY 2001 12/0 100% 0%
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TERLIPRESSINE
ANNEE n REPONSE SURVIE HSR I / II RENALE + 4 semaines
NERI 2008 52/0 80% 72%SANYAL 2006 56/0 34% 48%SOLANKI 2003 24/0 - -ORTEGA 2002 16/5 77% 88%MOREAU 2002 99/0 64% 37%HALIMI 2002 16/2 72% 42%URIZ 2000 6/3 77% 66%MULKAY 2001 12/0 100% 25%
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MIDODRINE
PEU DE DONNEES
PETITS COLLECTIFS
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MIDODRINE
14 PATIENTS SHR TYPE I
MIDODRINE 2,5 mg/jOCTREOTIDE 25µg/h ivseALBUMINE 50 g/j
REPONSE RENALE +10/14
HEPATOLOGY 2004; 40: 54
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MIDODRINE
14 PATIENTS SHR TYPE I – REPONDEURS n=10
HEPATOLOGY 2004; 40: 54
DEBIT SANGUIN RENAL
RESISTANCE VASC. RENALE
FE Na RENALE
RENINE
ALDOSTERONE
157650,6201
2574
22542
1,0439930
DEBIT FILTRATION GLOMER. 13 26
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NORADRENALINE
ETUDE PROSPECTIVE MONOCENTRIQUE 2 ANS
SHR TYPE I
REMPLISSAGE VASCULAIRE ALBUMINEDIURETIQUE / LASILIX PVC
>4 < 10 cm H2ODIURESE
> 100 mL/4h
ECHEC 48 h00
NORADRENALINE 0,5 mg/hMAX 3 mg/h
HEPATOLOGY 2002;36:374
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NORADRENALINE
0
200
400
600
800
0 5 10
CREATµmol/l
JOURS
HEPATOLOGY 2002;36:374
REGRESSION INS. RENALE = 83%
TRANSPLANTATION HEPATIQUE = 3
DECES = 5
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NORADRENALINE vs TERLIPRESSINE
J HEPATOL 2007; 47: 499
NORADRENALINEN=10
TYPE I/ II = 4/6
TERLIPRESSINEN=12
TYPE I/II = 5/7
ETUDE RANDOMISEE SIMPLE AVEUGLE
ALBUMINE QSP PVC 10 à 15 cm H2O
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NORADRENALINE TERLIPRESSINEDOSE 0,1 µg/kg.min-1 1 mg / 4H
ADAPTATION 4H [0,05] 3 jours
OBJECTIF PAM 10 mm Hg CREAT 25%
DOSE MAX 0,7 µg/kg.min-1 2mg / 4H
NORADRENALINE vs TERLIPRESSINE
J HEPATOL 2007; 47: 499
ETUDE RANDOMISEE SIMPLE AVEUGLE
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NORADRENALINE vs TERLIPRESSINE
REPONSE AU TRAITEMENT
1,5
2,5
3,5
4,5
T0 NORADRENALINE T0 TERLIPRESSINE
J HEPATOL 2007; 47: 499
70% 83%
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NORADRENALINE vs TERLIPRESSINE
J HEPATOL 2007; 47: 499
NORADRENALINEN=10
TERLIPRESSINEN=12
7/10 TRANSPLANTATION 8/12 TRANSPLANTATION
107 EUROS 1536 EUROS
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TIPS
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ANNEE n REPONSE TEMPS DE ENCEPH. CI HSR I / II RENALE + SURVIE TIPS
WONG 2004 5/1 - ? 50%
TESTINO 2003 0/18 - ? ?
BRENSING 2000 14/17 81% 81% (3mois) 35% 32% 16% GRAVE
GUEVARA 1998 7/0 86% 140 j 71% ?
BRENSING 1997 6/10 81% 75% (3mois) ? ?LAKE 1993 8 62%
TIPS
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COUT
FAIBLE SURVIE
ENCEPHALOPATHIE
ETUDERANDOMISEE ?
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COÛT
FAIBLE SURVIE
ENCEPHALOPATHIE
Dysfonction hépatiquesévère
EncéphalopathieHépatique
Thrombose porte
ETUDERANDOMISEE ?
CONTRE INDICATION
Bili > 85 µmol/l - CP > 12
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TRAITEMENT COMBINE
14 PATIENTS SHR TYPE IMIDODRINEOCTREOTIDEALBUMINE
TIPS
MOIS
0
40
80
120
160
Avant Après 1er 3ème 6ème 12ème
0
40
80
120
160Débit filtrationglomérulaire
ml/min
Excrétion sodéemmol/l
TIPS
HEPATOLOGY 2004; 40: 54
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TRAITEMENT COMBINE
14 PATIENTS SHR TYPE IMIDODRINEOCTREOTIDEALBUMINE
TIPS
MOIS
Débit sanguin rénalmL.min-1
Résistance vasculaireRénale
Dyn.sec.cm-5TIPS
0
100
200
300
400
Avant Après 1er 3ème 6ème 12ème
0
2000
4000
6000
8000
HEPATOLOGY 2004; 40: 54
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TRAITEMENT COMBINE
14
4NON REPONDEURS
DECES
10REPONDEURS
5TIPS
4VIVANTS
5NON TIPS
3DECES
3TRANSPLANTES
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TRAITEMENT PREVENTIF
PERITONITE BACTERIENNE SPONTANEE
PARACENTESE
HEPATITE ALCOOLIQUE AIGUE
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PERITONITE BACTERIENNE SPONTANEE
Cefotaxime vs Cefotaxime + albumine seul
(n=63) (n=63)
INS. RENALE (%) 10 33MORTALITE (%)- HOSPITALIERE 10 29- 3 MOIS 22 41
Alb 1,5 g/kg J0 1 g/kg J3
N ENGL J MED 1999;341:403
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“DYSFONCTION CIRCULATOIRE” INDUITEPARACENTESE
37 patients H ascite PARACENTESE (~ 7 L) + DEXTRAN
J0 J6
Activité rénine 9 29Aldostérone 109 187Noradrénaline 752 1223Créatinine 0,95 1,26
Plasma
GASTROENTEROLOGY 1997; 113: 579
27% DYSFONCTION CIRCULATOIRE
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EGALITE SOLUTES DE SUBSTITUTION ?
289 PATIENTS ASCITIQUES
ALBUMINE DEXTRAN 70 POLYGELINE n=97 n=93 n=99
18 % 34 % 38 %
GASTROENTEROLOGY 1996; 111:1002
MORTALITE IDENTIQUE
ETUDE MULTICENTRIQUE
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Péritonite bactérienne spontanée-HEA vs Albumine 20% -
↓↔
31
HEPATOLOGY 2005; 42: 627
+ ++
HEA ALBUMINE 20% 200 / 0,5 – 6%
n=10 n=10HEMODYNAMIQUESYSTEMIQUE
RENINE
DYSFONCTIONCIRCULATOIRE
INS. RENALE
00
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0
10
20
30
40
50
60
70
< 5 L 5 à 9 L > 9 L
ALBUMINE
POLYGELINE
VOLUME DE PARACENTESE
% PATIENTSDYSFONCTIONCIRCULATOIRE
p = 0,04
p = 0,02
GASTROENTEROLOGY 1996; 111:1002
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0
10
20
30
40
50
60
< 6 Litres >=6 Litres
HEPATOLOGY 2003; 37:1147
SERUM SALE 3,5%
ALBUMINE
VOLUME DE PARACENTESE
% PATIENTSDYSFONCTIONCIRCULATOIRE
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HEPATITE ALCOOLIQUE AIGUË
ETUDE RANDOMISEE DOUBLE AVEUGLE(score de Maddrey ≥ 32)
PENTOXYFILLINE400 mg x 3/jour
n=49
PLACEBOn=52
PENTOX. PLACEBO
MORTALITE (n) 12 24SHR 6 22
GASTROENTEROLOGY 2000; 119:1637
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0
250
500
750
1000
0 2 4 6 8 10 12 14 16
0
500
1000
1500
2000Terlipressine [0,5 x 2/j
puis 0,5 x 4/j] et remplissage
Remplissage
CREATININE (µmol/l)DIURESE (mL)
JOURS
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TERLIPRESSINE
ETUDE PROSPECTIVE RANDOMISEE SIMPLE AVEUGLE
24 PATIENTS
TERLIPRESSINE1 mg / 12h
n=12
CONTROLE
n=12
ALBUMINE 10 g/j ET PFC 150 mL/8h
DOPAMINE 4µg/kg.min-1
NORMALISATION SHRSURVIE J15
J GASTROENTEROL HEPATOL 2003; 18: 152
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TERLIPRESSINE
J0 J4 J8 J15SURVIE T 12 11 9 5
C 12 10 7 0CREAT T 2,9 2,7 1,6 1,2
C 2,2 2,7 3,9 -
CL/CREAT T 18 20 35 64 C 17 11 9 -
J GASTROENTEROL HEPATOL 2003; 18: 152
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MIDODRINE
MIDODRINE + OCTREOTIDE DOPAMINEn=5 n=8
0
2
4
6
8
0 3 10 20
Créatmg/l
Jours
Mortalité90%
HEPATOLOGY 1999; 29: 1690