Hepatorenal syndrome: Difference between revisions
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==Background== | ==Background== | ||
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* Arterial vasodilatation in the splanchnic circulation, which is triggered by portal hypertension | * Arterial vasodilatation in the splanchnic circulation, which is triggered by portal hypertension | ||
*Diagnosis of exclusion | *Diagnosis of exclusion | ||
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*Type 2 | *Type 2 | ||
**Gradual impairment in renal function (that may not advance beyond moderate) | **Gradual impairment in renal function (that may not advance beyond moderate) | ||
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**Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnormal kidneys on U/S | **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]]) | *Drug-induced renal failure ([[Special:MyLanguage/NSAIDs|NSAIDs]], [[Special:MyLanguage/aminoglycosides|aminoglycosides]]) | ||
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**Urine RBC <50 cells/hpf | **Urine RBC <50 cells/hpf | ||
**Serum sodium <130 mEq/L | **Serum sodium <130 mEq/L | ||
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**Avoid diuretics and benzodiazepines | **Avoid diuretics and benzodiazepines | ||
**Discuss giving octreotide and/or midodrine with admitting physician | **Discuss giving octreotide and/or midodrine with admitting physician | ||
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*Should be evaluated at liver transplant center | *Should be evaluated at liver transplant center | ||
*May require TIPS, vasoconstrictors as bridge to transplant | *May require TIPS, vasoconstrictors as bridge to transplant | ||
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[[Category:GI]] | [[Category:GI]] | ||
[[Category:Renal]] | [[Category:Renal]] | ||
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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