Hepatorenal syndrome: Difference between revisions
No edit summary |
Ostermayer (talk | contribs) (Prepared the page for translation) |
||
| (34 intermediate revisions by 7 users not shown) | |||
| Line 1: | Line 1: | ||
<languages/> | |||
<translate> | |||
==Background== | ==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== | ==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 | *NEJM vol 361 no 13 P. Gines | ||
<references/> | |||
[[Category:GI]] | |||
[[Category:Renal]] | |||
</translate> | |||
Latest revision as of 23:04, 4 January 2026
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
- Parenchymal renal disease
- Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnormal kidneys on U/S
- Drug-induced renal failure (NSAIDs, aminoglycosides)
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:
- 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
See Also
References
- NEJM vol 361 no 13 P. Gines
- ↑ Deepika D et al. Hepatorenal Syndrome Workup. Dec 27, 2015. http://emedicine.medscape.com/article/178208-workup#showall