View source for Hepatorenal syndrome

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==Background==

*[[Special:MyLanguage/Acute renal failure|Acute renal failure]] in patient with normal kidneys in presence of acute/chronic hepatic failure 
*Often heralded by the presence of [[Special:MyLanguage/SBP|SBP]]
* Arterial vasodilatation in the splanchnic circulation, which is triggered by portal hypertension
*Diagnosis of exclusion


==Clinical Features==

*Type 1
**Doubling of serum creatinine over a 2-week period
**Progressive oliguria
*Type 2
**Gradual impairment in renal function (that may not advance beyond moderate)


==Differential Diagnosis==

*Hypovolemia-induced renal failure
**[[Special:MyLanguage/GI bleed|GI bleed]]
**[[Special:MyLanguage/Diuretics|Diuretics]]
**[[Special:MyLanguage/Diarrhea|Diarrhea]]
*Parenchymal renal disease
**Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnormal kidneys on U/S
*Drug-induced renal failure ([[Special:MyLanguage/NSAIDs|NSAIDs]], [[Special:MyLanguage/aminoglycosides|aminoglycosides]])


==Evaluation<ref>Deepika D et al. Hepatorenal Syndrome Workup. Dec 27, 2015. http://emedicine.medscape.com/article/178208-workup#showall</ref>==

*[[Ultrasound: Abdomen|Abdominal US]]
*Diagnostic [[Special:MyLanguage/paracentesis|paracentesis]]
*Ascites fluid cultures and analysis
*Labs:
**CBC with diff
**BMP
**[[Special:MyLanguage/LFTs|LFTs]]
**Blood cultures
**[[Special:MyLanguage/Urinalysis|Urinalysis]]
**Urine electrolytes and osmolality
**Consultants: alpha-fetoprotein, cryoglobulins
*All major criteria must be met for diagnosis for both HRS types 1 and 2:
**Serum creatinine >1.5mg/dL
**No improvement in renal function after halting diuretics AND admin of 1.5 L of plasma expander
**[[Special:MyLanguage/Proteinuria|Proteinuria]] <500mg/d
**No [[Special:MyLanguage/ultrasound|ultrasound]] evidence of obstructive uropathy or renal parenchymal disease
**Absence of shock, bacterial infection, hypovolemia, nephrotoxic meds
*Supporting criteria not required for diagnosis:
**Uop <500 cc/day
**Urine sodium <10 mEq/L
**Urine osmolality > plasma osmolality
**Urine RBC <50 cells/hpf
**Serum sodium <130 mEq/L


==Management==

*[[Special:MyLanguage/Vasopressors|Vasopressors]]
**Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
**[[Special:MyLanguage/Norepinephrine|Norepinephrine]]: 0.5-3mg/hr to increase MAP by 10mmHg
**[[Special:MyLanguage/Midodrine|Midodrine]]: 7.5mg PO tid with Octreotide 100mcg sq
*Albumin: 1-1.5g/kg with one of above
*Other:
**[[Special:MyLanguage/TIPS|TIPS]], [[Special:MyLanguage/hemodialysis|renal replacement therapy]]
**Avoid diuretics and benzodiazepines
**Discuss giving octreotide and/or midodrine with admitting physician


==Disposition==

*1-month survival: 50%
*6-month survival: 20%
*Should be evaluated at liver transplant center
*May require TIPS, vasoconstrictors as bridge to transplant


==See Also==


==References==

*NEJM vol 361 no 13 P. Gines
<references/> 
[[Category:GI]]
[[Category:Renal]]
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