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The following is an archived discussion of a featured article nomination. Please do not modify it. Subsequent comments should be made on the article's talk page or in Wikipedia talk:Featured article candidates. No further edits should be made to this page.

The article was promoted by SandyGeorgia 02:00, 3 August 2009 [1].

Hepatorenal syndrome

[edit]
Nominator(s): Samir 07:10, 12 July 2009 (UTC)[reply]
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Meets all criteria in my opinion. The article recently went through WP:GAR where many additions were made. I invited many of our medical types and non-medical types to look over the text over the past month. All images are free; it was a challenge for me to find the TIPS image. I look forward to everyone's comments -- Samir 07:10, 12 July 2009 (UTC)[reply]

  • Ok. I have placed ALT text on the schematics as: "Diagram: portal hypertension leads to splanchnic vasoconstriction, which decreases effective cirulatory volume. This leads to ascites due to renal sodium avidity and HRS due to renal vasoconstriction" and "Diagram: ascites, diuretic-resistant ascites and HRS are a spectrum. All occur in portal hypertension. Diuretic-resistance occurs with splanchnic vasodilation. When it progresses to renal vasoconstriction, HRS occurs." It is a little lengthy but explains the two images well. I have added the text: "Two part stained slide of altered cells of the liver on top labelled as alcoholic cirrhosis and cells of the kidney on the bottom labelled as being normal". Thoughts? Should the schematic ALT texts be shortened? -- Samir 18:43, 12 July 2009 (UTC)[reply]
  • There's a basic test that medical articles should pass, which I call the "Johnny test". Mom: "The doctor says that your uncle has something called hepatorenal syndrome." Johnny: What's that? Let me look it up on Wikipedia." Can Johnny get a useful answer? To some degree yes, but there's too much jargon. The first paragraph of the lead, at least, should give Johnny an overview he can understand, without jargon. How about something like this:


I'm not an expert and probably got some things wrong here: I'm mainly trying to illustrate the level I believe the intro to a medical FA should aim for. Looie496 (talk) 18:41, 14 July 2009 (UTC)[reply]
You're right, needs some tweaking. Working on it, need a little but not much time. Thanks -- Samir 03:06, 17 July 2009 (UTC)[reply]
Ok, how does the lead read now? I think it is very good personally -- Samir 06:57, 17 July 2009 (UTC)[reply]
Great, concise and informative but easy to understand. Looie496 (talk) 02:43, 18 July 2009 (UTC)[reply]
  • Comment this is an excellent and comprehensive article, but I agree with the above that the prose needs simplifying. For example, the phrase 'in the setting of' appears 8 times by my count, and sounds like doctor-speak in a way that may be off-putting to laypeople. As a minor aside, the two diagrams have jpeg jaggies; convert to SVG? Opabinia regalis (talk) 03:29, 16 July 2009 (UTC)[reply]
  • Comment: sorry it has taken me a week to come and comment on this excellent article. It covers all the important aspects and I cannot detect any omissions or factual problems. I was still hoping that the following issues could be addressed:
    • There's a fair number of primary sources, and I'm not entirely sure if each of these is backed up by a secondary source affirming their relative prominence in the evidence food chain.
    • The word "Type" as in "Type 1" is capitalised. Could you clarify if this is in keeping with the WP:MOS (can't seem to find the relevant point).
    • Clearly, if you have HRS, you'd like to be in Barcelona. Is there a source confirming that this seems to be the world capital of ascites/HRS currently? JFW | T@lk 11:31, 19 July 2009 (UTC)[reply]
      • Hi JFW -- yes I agree we are top heavy on the primary cites. I think we reference all of the major review articles. I will tighten the citations -- need a bit of time but not too long. The "Type 1" vs. "type 1" convention is not standardized in the literature. Couldn't find anything in WP:MEDMOS. The portal hypertensive basic research, the database work on portal hypertensive complications, and the terlipressin data are all from Barcelona. The midodrine/octreotide work was from Italy (Padua) and the TIPS work is from Toronto. MARS work and the transplant data are from a number of centres. -- Samir 04:51, 20 July 2009 (UTC)[reply]
      • To follow-up: (1) primary sources are now backed by one of the major review articles as secondary sources; (2) "type" has been changed to lowercase as the majority of review articles have it lowercase; (3) I can't find a reference for Barcelona as the major centre for HRS research, probably best if we do not reference that imo -- Samir 05:48, 22 July 2009 (UTC)[reply]
      • Support, clearly ready for FA. JFW | T@lk 23:03, 22 July 2009 (UTC)[reply]
  1. From "Signs and symptoms": "The urine produced by individuals with HRS has a very low concentration of sodium, and typically does not contain cellular material when analyzed by microscopy. Detailed criteria for the diagnosis of HRS have been defined based on laboratory data and the clinical circumstances of the affected individual." These features are neither signs nor symptoms.
  2. From "Causes", paragraph 2: "iatrogenic precipitants of HRS include the aggressive use of diuretic medications". Is this correct? Isn't this a cause of hypovolaemia?
  3. From "Diagnosis", paragraph 2: "treatment with 1.5 litres of intravenous normal saline". Doesn't saline cause worsening ascites and oedema?
  4. From "Diagnosis", paragraph 3: " there is impairment of the ability of the renal tubules to concentrate urine in ATN, leading to urine sodium measurements that are much higher than in HRS". In ATN, tubules are unable to concentrate urine. Also, the urine sodium in ATN is high; higher than in HRS. However is it correct that the impaired concentration leads to high urinary sodium?
  5. I like the diagrams in the "Pathophysiology" section.
  6. Regarding the photo in the "Prevention" section, it may be helpful to say that this is an endoscopic view of the inside of the oesophagus.
  7. From "Prevention", paragraph 1: "removal of ascitic fluid may improve renal function if it decreases the pressure on the renal veins." Are you sure it's the veins, not the arteries?

Axl ¤ [Talk] 09:46, 22 July 2009 (UTC)[reply]

Hi Axl. Thanks very much for looking things over for the article.
  1. For signs and symptoms -- Rewritten. I have removed the urinary findings as they are rightly not signs and symptoms (and are mentioned elsewhere). I also re-wrote the last line to make the point that signs and symptoms do not make the diagnosis of HRS
  2. Causes para 2 -- yes diuretic medications are a common trigger for the hemodynamic changes in cirrhotics that lead to HRS
  3. Diagnosis para 2 -- yes the way to distinguish HRS from pre-renal failure is to "force" euvolemia by giving 1.5 L of NS to an affected individual (in pre-renal failure, the renal failure would improve and U Na would rise)
  4. Diagnosis para 3 -- re-written. Agree, I worded it wrong and it was confusing before. Hopefully it reads better now.
  5. Prevention photo -- added reference to esophagus to caption
  6. Prevention -- yes large volume paracentesis is supposed to decrease pressure on the renal veins (arterial pressure would not be affected) leading to improved renal function. This is classic teaching handed down from Sheila Sherlock's original text on liver diseases, but there has been little work evaluating it in the recent literature. -- Samir 17:16, 22 July 2009 (UTC)[reply]
Samir, thanks for clarifying (and educating me!). I support the application for FA status. Axl ¤ [Talk] 17:40, 22 July 2009 (UTC)[reply]
  • Comment - I will begin now to take a look and likely make some straightforward copyediting changes as I go. Please feel free to revert any that inadvertently change the meaning. I will note queries below. Casliber (talk · contribs) 04:50, 26 July 2009 (UTC)[reply]
  • Wow, I am impressed - you've navigated the tightrope between medical exactness and plain english very very well! I was reduced to minor nitpicky things. It is comprehensive and I can't see any reason not to Support Casliber (talk · contribs) 05:07, 26 July 2009 (UTC)[reply]
  • No problem. Just for the future, when you upload images like this one, could you point your links to the exact flickr image instead of the photostream and upload the images to Commons rather than Wikipedia? Thanks, NW (Talk) 15:03, 26 July 2009 (UTC)[reply]

Full support with Comments - What on earth does this mean, "The minor criteria are laboratory in nature"? And here, "Some viral infections of the liver, including hepatitis B and hepatitis C can also lead to inflammation of the glomerulus of the kidney", as far as I can tell, the reference only refers to chronic hepatitis B virus infections. And this, I think, is a mixed metaphor "Contributions by Murray Epstein cemented splanchnic vasodilation and renal vasoconstriction as hallmarks of the syndrome"— but no big deal. Graham Colm Talk 14:29, 27 July 2009 (UTC)[reply]

Hi Graham, I rewrote the two sentences in a clearer manner [2] [3] and added the reference to a nice 2001 review of renal diseases in hepatitis C. [4] Thanks -- Samir 01:13, 28 July 2009 (UTC)[reply]
The above discussion is preserved as an archive. Please do not modify it. No further edits should be made to this page.
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