Hepatorenal syndrome: Difference between revisions

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==Pathophysiology==
==Background==
Functional renal vasoconstriction leading to severe redxn in GFR with minimal renal histologic abnormalities
*[[Acute renal failure]] in patient with normal kidneys in presence of acute/chronic hepatic failure
*Often heralded by the presence of [[SBP]]
* Arterial vasodilatation in the splanchnic circulation, which is triggered by portal hypertension
*Diagnosis of exclusion


==Diagnosis==
==Clinical Features==
#Type 1: doubling of serum Cr to > 2.5mg/dl in < 2wk
*Type 1
#Type 2: stable or less rapidly progressive course than Type 1
**Doubling of serum creatinine over a 2-week period
#Type 1 & 2 both require^:
**Progressive oliguria
##Cr >1.5mg/dl
*Type 2
##Cr NOT reduced below 1.5mg/dl with administration of albumin (1g/kg) and after a minimum of 2 days off diuretics
**Gradual impairment in renal function (that may not advance beyond moderate)
##Abscence of current or recent rx with potentially nephrotoxic drugs
##Abscence of shock
##Abscence of renal parenchymal disease (urinary excretion of >500mg protein/d, >50 RBC/hpf, abnl kidneys on U/S)


==DDx==
==Differential Diagnosis==
#Hypovolemia-induced renal failure (GI bleed or fluid losses 2/2 diuretics, diarrhea most common)
*Hypovolemia-induced renal failure
#Parenchymal renal disease (proteinuria >500mg protein/d, >50 RBC/hpf or both; confirmed with renal biopsy)
**[[GI bleed]]
#Drug-induced renal failure (current NSAIDs, aminoglycosides)
**[[Diuretics]]
**[[Diarrhea]]
*Parenchymal renal disease
**Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnormal kidneys on U/S
*Drug-induced renal failure ([[NSAIDs]], [[aminoglycosides]])


==Treatment==
==Evaluation<ref>Deepika D et al. Hepatorenal Syndrome Workup. Dec 27, 2015. http://emedicine.medscape.com/article/178208-workup#showall</ref>==
#Vasoconstrictors
*[[Ultrasound: Abdomen|Abdominal US]]
##Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
*Diagnostic [[paracentesis]]
##Norepi: 0.5-3mg/hr to increase MAP by 10mmHg
*Ascites fluid cultures and analysis
##Midrodrine: 7.5mg PO tid with Octreotide 100mcg sq
*Labs:
#Albumin: 1-1.5g/kg with one of above
**CBC with diff
#Other: TIPS, renal replacement therapy
**BMP
**[[LFTs]]
**Blood cultures
**[[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
**[[Proteinuria]] <500mg/d
**No [[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==
*[[Vasopressors]]
**Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
**[[Norepinephrine]]: 0.5-3mg/hr to increase MAP by 10mmHg
**[[Midodrine]]: 7.5mg PO tid with Octreotide 100mcg sq
*Albumin: 1-1.5g/kg with one of above
*Other:
**[[TIPS]], [[hemodialysis|renal replacement therapy]]
**Avoid diuretics and benzodiazepines
**Discuss giving octreotide and/or midodrine with admitting physician


==Disposition==
==Disposition==
#1-month survival: 50%
*1-month survival: 50%
#6-month survival: 20%
*6-month survival: 20%
 
*Should be evaluated at liver transplant center
==Source==
*May require TIPS, vasoconstrictors as bridge to transplant
Adapted from NEJM vol 361 no 13 P. Gines


^International Ascites Club criteria
==See Also==


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

Latest revision as of 12:38, 24 April 2021

Background

  • Acute renal failure in patient with normal kidneys in presence of acute/chronic hepatic failure
  • Often heralded by the presence of 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

Evaluation[1]

  • Abdominal US
  • Diagnostic paracentesis
  • Ascites fluid cultures and analysis
  • Labs:
    • CBC with diff
    • BMP
    • LFTs
    • Blood cultures
    • 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
    • Proteinuria <500mg/d
    • No 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

  • Vasopressors
    • Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
    • Norepinephrine: 0.5-3mg/hr to increase MAP by 10mmHg
    • Midodrine: 7.5mg PO tid with Octreotide 100mcg sq
  • Albumin: 1-1.5g/kg with one of above
  • Other:

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
  1. ↑ Deepika D et al. Hepatorenal Syndrome Workup. Dec 27, 2015. http://emedicine.medscape.com/article/178208-workup#showall
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