Hepatorenal syndrome

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

• Hypovolemia-induced renal failure
  • GI bleed
  • 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)

Evaluation

• 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:
  • TIPS, 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

References

• NEJM vol 361 no 13 P. Gines