Hepatorenal syndrome is a condition in which there is progressive kidney failure in a person with cirrhosis of the liver. It is a serious and often life-threatening complication of cirrhosis.

Hepatorenal syndrome occurs when there is a decrease in kidney function in a person with a liver disorder. Because less urine is removed from the body, nitrogen-containing waste products build up in the bloodstream (azotemia).

The disorder occurs in up to 10% of patients hospitalized with liver failure. It is caused by the mounting effects of liver damage and leads to kidney failure in people with:

• Acute liver failure
• Alcoholic hepatitis
• Cirrhosis

Risk factors include:

• Blood pressure that falls when a person rises or suddenly changes position (orthostatic hypotension)
• Diuretic use
• Gastrointestinal bleeding
• Infection
• Recent abdominal fluid tap (paracentesis)

• Abdominal swelling due to fluid (called ascites, a symptom of the underlying liver disease)
• Change in mental status
  • Confusion
  • Delirium
  • Dementia
• Coarse muscle movements or mucle jerks
• Dark-colored urine (a symptom of the underlying liver disease)
• Decreased urine production
• Nausea and vomiting
• Weight gain
• Yellow skin(jaundice, a symptom of the underlying liver disease)

This condition is diagnosed when other causes of kidney failure are ruled out by the appropriate tests.

A physical examination does not directly reveal kidney failure. However, the exam will usually show signs of chronic liver disease:

• Confusion (often due due to hepatic encephalopathy)
• Excess fluid in the abdomen (ascites)
• Jaundice
• Other signs of liver failure

Other signs include:

• Abnormal reflexes
• Decreased testicle size
• Dull sound in the abdomen when tapped with the tips of the fingers, and visible fluid wave when examined by feel
• Increased breast tissue (gynecomastia)
• Sores (lesions) on the skin

The following may be signs of kidney failure:

• Absent or low urine production, less than 400 cc/day
• Fluid retention in the abdomen or extremities
• Increased BUNand serum creatinine levels
• Increased urine specific gravity and osmolality
• Low serum sodium
• Very low urine sodium concentration

The following may be signs of liver failure:

• Abnormal prothrombin time (PT)
• Increased serum ammonia levels
• Low serum albumin
• Paracentesisshows ascites
• Signs of hepatic encephalopathy (an EEG may be performed if such signs are present)

Treatment aims to improve liver function and ensure that there is enough blood volume in the body and that the heart is pumping it adequately.

The disorder is generally treated in the same way as kidney failure from any other cause.

• All unnecessary medicines should be stopped, especially the antibiotic neomycin, ibuprofen and other NSAIDs, and diuretics ("water pills").
• Dialysis may improve symptoms.
• Medications such as octreotide plus midodrine, albumin, or dopamine may be used temporarily to improve kidney function.
• A nonsurgical shunt (known as TIPS) is used to relieve the symptoms of ascites and may help kidney function. Surgery to place a shunt (called a Levine shunt) from the abdominal space (peritoneum) to the jugular vein may also relieve some of the symptoms of kidney failure. Both procedures are risky and proper selection of patients is very important.

The predicted outcome is poor. Death usually occurs as a result of secondary infections or hemorrhage.

• Bleeding
• Damage to, and failure of, many organ systems
• End-stage kidney disease
• Fluid overload with congestive heart failure or pulmonary edema
• Hepatic coma
• Secondary infections

This disorder most often is diagnosed in the hospital during treatment for a liver disorder.

Garcia-Tsao G. Cirrhosis and its sequellae. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier. 2007: chap 157.

Schuppan D, Afdhal NH. Liver cirrhosis. Lancet. 2008;371:838-851.

According to the Mayo Clinic, (which is what they profess) there is no 'specific' chronic fatigue syndrome treatment. -However, here is some advice that I have found that may help.

ANY COMBINATION OF:

* Moderating daily activity. Your doctor may encourage you to slow down and to avoid excessive physical and psychological stress. However, too much rest can make you weaker, worsening your long-term symptoms. Your goal should be to maintain a moderate level of daily activity and gently increase your stamina over time.

* Gradual but steady exercise. Often with the help of a physical therapist, you may be advised to begin an exercise program that slowly becomes more challenging. Research has proved that gradually increasing exercise can improve the symptoms of chronic fatigue syndrome.

* Cognitive behavior therapy. This treatment, often used in combination with graduated exercise, also has been found to improve the symptoms of chronic fatigue syndrome. In cognitive behavior therapy, you work with a mental health professional to identify negative beliefs and behaviors that might be delaying your recovery and replace them with healthy, positive ones.

* Treatment of depression. If you're depressed, medications, such as tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs), may help. Antidepressants may also help improve sleep and relieve pain.

* Treatment of existing pain. (For what it's worth) Acetaminophen (Tylenol, others) and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen (Advil, Motrin, others), may be helpful to reduce pain and fever.

* Treatment of low blood pressure (hypotension). The drugs fludrocortisone (Florinef), atenolol (Tenormin) and midodrine (ProAmatine, Orvaten) may be useful.

* Treatment for problems of the nervous system. Symptoms such as dizziness and extreme skin tenderness can sometimes be relieved by clonazepam (Klonopin). Your doctor may prescribe medications to relieve symptoms of anxiety.

??? HERBAL REMEDIES ???

* Intramuscular magnesium for people with low red blood cell magnesium, a combination of fish oil and evening primrose oil, melatonin, NADH, propionyl-L-carnitine, and ribose - have be known to show encouraging results.

* From what I have gathered, there is insufficient evidence of benefit to recommend any specific dietary or herbal supplements as a treatment for chronic fatigue, (other than what I mentioned). === === === === === === Chronic pain can be cured with different types of massage therapies, physical therapy meditation, yoga, acupuncture and acupressure. People suffer from chronic pain because of several reasons: it could be an injury from an accident, diseases like arthritis, stiffness, aging, or, muscle damage. Yoga is one way to deal with chronic pain. While attending a class with other people might have several benefits. According to yoga chronic pain is purely psychosomatic syndrome. Pranayama breathing techniques in yoga can help relieve pain. Generally, when we are in pain, we tend to hold our breaths, thus building up toxins in our body. So people who have pain, generally have poor circulation, and contracted muscles. Yoga breathing can combat this and help you overcome the problem.

Multiple system atrophy (MSA) is a rare condition that causes symptoms similar to Parkinson's disease. However, patients with MSA have more widespread damage to the autonomic nervous system. This is the part of the nervous system that controls important organ functions such as heart rate, blood pressure, digestive system muscles, and sweating.

Shy-Drager syndrome; Neurologic orthostatic hypotension; Shy-McGee-Drager syndrome; Parkinson's plus syndrome

The cause is unknown. MSA develops gradually and is most often diagnosed in men older than 60.

MSA damages the nervous system, which can cause the following symptoms:

• Changes in facial expression
  • "Mask" appearance to face
  • May be unable to close mouth
  • Reduced ability to show facial expressions
  • Staring
• Difficulty chewing or swallowing (occasionally)
• Disrupted sleep patterns (especially during rapid eye movement (REM) sleep late at night)
• Dizziness or fainting when standing up or after standing still
• Frequent falls
• Impotence
• Loss of control over bowels or bladder
• Loss of fine motor skills
  • Difficulty eating
  • Difficulty with any activity that requires small movements
  • Writing that is small and hard to read
• Loss of sweating in any part of the body
• Mild decline in mental function (may occur)
• Movement difficulties
  • Loss of balance
  • Shuffling
  • Walking pattern (gait) changes
• Muscle achesand pains (myalgia)
• Muscle rigidity
  • Difficulty bending arms or legs
  • Stiffness
• Nausea and problems with digestion
• Posture difficulties: may be unstable, stooped, or slumped over
• Slow movements
  • Difficulty beginning to walk or starting any voluntary movement
  • Freezing of movement when the movement is stopped, unable to start moving again
  • Small steps followed by the need to run to keep balance
• Tremors
  • May become severe enough to interfere with activities
  • May be worse when tired, excited, or stressed
  • May occur at rest or at any time
  • May occur with any action, such as holding a cup or other eating utensils
  • Finger-thumb rubbing (pill rolling tremor)
• Vision changes, decreased or blurred vision
• Voice and speech changes
  • Difficulty speaking
  • Monotone
  • Slow speaking
  • Voice is low volume

Other symptoms that may occur with this disease:

• Confusion
• Dementia
• Depression
• Sleep-related breathing difficulties, especially sleep apnea and a blockage in the air passage that leads to a harsh vibrating sound
• Seborrheic dermatitis

The health care provider may perform the following:

• Blood pressuremeasurement, lying and standing
• Eye examination
• Nerve and muscle (neuromuscular) examination

There are no specific tests to confirm this disease. A neurologist can make the diagnosis based on:

• History of symptoms
• Findings during a physical examination
• Ruling out other causes of symptoms

Testing to help confirm the diagnosis may include:

• MRI of head
• Plasma norepinephrine levels
• Urine examination for norepinephrine breakdown products (urine catecholamines)

There is no cure for MSA, and there is no known way to prevent the disease from getting worse. The goal of treatment is to control symptoms.

Anticholinergic medications may be used to reduce early or mild tremors. Levodopa may improve movement and balance.

Carbidopa may reduce the side effects of Levodopa and make it work better. However, the response to medications may be disappointing. Many people respond poorly to treatment with anticholinergics or Levodopa.

Medications that may be used to treat low blood pressure include:

• Beta-blockers
• Fludrocortisone (Florinef)
• MAO inhibitors
• Vasoconstrictors (midodrine)
• Vasopressin

A pacemaker that is programmed to stimulate the heart to beat at a rapid rate (faster than 100 beats per minute) may increase blood pressure for some people.

Constipation can be treated with a high-fiber diet and laxatives. Impotence may be treated with drugs that enhance erections.

The outcome is poor. Loss of mental and physical functions slowly get worse. Early death is likely.

• Progressive loss of ability to walk or care for self
• Difficulty performing daily activities
• Injuries from falls/fainting
• Side effects of medications

Call your health care provider if you develop symptoms of this disorder.

Call your health care provider if you have been diagnosed with MSA and your symptoms return or get worse. Also call if new symptoms appear, including possible side effects of medications:

• Changes in alertness/behavior/mood
• Delusional behavior
• Dizziness
• Hallucinations
• Involuntary movements
• Loss of mental functioning
• Nausea/vomiting
• Severe confusion or disorientation

Contact your health care provider if you have a family member with this disorder and his or her condition deteriorates to the point that you are unable to care for the person at home.

Lang A. Parkinsonism. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 433.