Review article: renal function assessment in cirrhosis - difficulties and alternative measurements.

BACKGROUND: Renal function in patients with cirrhosis is important prognostically, both before and following liver transplantation. Its prognostic impact is reflected by the inclusion of serum creatinine in the model for end-stage liver disease score, which is now used for recipient prioritization on liver transplantation waiting lists in the USA. AIM: To review the accuracy of the surrogate markers for the assessment of renal function, i.e. glomerular filtration rate, particularly in patients with cirrhosis. METHOD: We reviewed the available literature in PubMed regarding the markers for GFR evaluation and the factors which affect their accuracy in cirrhosis. RESULTS: Although creatinine is widely available, it is an unreliable marker of glomerular filtration rate, particularly in patients with cirrhosis. Clearance of exogenous markers is considered the 'gold standard', but this methodology has many drawbacks, particularly poor applicability. Several mathematical formulae for estimated glomerular filtration rate are used to overcome some of these limitations: Cockcroft-Gault and Modification of Diet in Renal Disease formulae are the most frequently applied, but they are based on serum creatinine. CONCLUSIONS: Due to the inaccuracy of serum creatinine and its derived formulae in estimating glomerular filtration rate, alternative serum markers, such as cystatin C, and new formulae are desirable. These need formal evaluation in patients with cirrhosis so as to have a reliable surrogate of glomerular filtration rate, and to obviate many problems that are associated with using creatinine and estimated glomerular filtration rate.

Hemobilia: four case reports and review of the literature.

In this report, we present four cases of hemobilia. Hemobilia occurs when conditions produce an abnormal communication between blood vessels and bile ducts. Although iatrogenic procedures as causes of hemobilia have been reported with increasing frequency, non-iatrogenic etiologies are still quite rare. We, therefore, report 4 cases of hemobilia secondary to different etiologies found in our institution from 1996 to 1998, that are non-iatrogenic. The first patient was a case of congenital aneurysm, the second pseudoaneurysm from trauma, the third cholangiocarcinoma and the fourth hepatocellular carcinoma. The classical triad consists of melena, jaundice and abdominal pain. Direct observation of blood flowing from the Ampulla of Vater by endoscopy was the initial diagnostic procedure in all four cases. Diagnosis was confirmed by ultrasonography, computerized tomography, angiography or surgery. Transcatheter selective embolization as a noninvasive treatment for hepatic aneurysm/pseudoaneurysm is emphasized.