Hepatorenal syndrome: Difference between revisions
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*Drug-induced renal failure ([[NSAIDs]], [[aminoglycosides]]) | *Drug-induced renal failure ([[NSAIDs]], [[aminoglycosides]]) | ||
==Diagnosis== | ==Diagnosis<ref>Deepika D et al. Hepatorenal Syndrome Workup. Dec 27, 2015. http://emedicine.medscape.com/article/178208-workup#showall</ref>== | ||
*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: | |||
**Serum Cr >1.5 mg/dL | |||
**No improvement in renal function after halting diuretics AND admin of 1.5 L of plasma expander | |||
**Proteinuria <500 mg/d | |||
**No US 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 | |||
==Treatment== | ==Treatment== | ||
Revision as of 19:17, 11 January 2016
Background
- Acute renal failure in pt w/ nl kidneys in presence of acute/chronic hepatic failure
- Often heralded by the presence of SBP
- Cause is unknown
Clinical Features
- Type 1
- Doubling of serum Cr over a 2-week period
- Progressive oliguria
- Type 2
- Gradual impairment in renal function (that may not advance beyond moderate)
Type 1 & 2 both require:
- Cr >1.5mg/dl
- Cr not reduced below 1.5 w/ albumin (1g/kg) and after minimum of 2 days off diuretics
- Absence of current or recent rx with potentially nephrotoxic drugs
- Absence of shock
- Absence of renal parenchymal disease:
Differential Diagnosis
- Hypovolemia-induced renal failure
- Parenchymal renal disease
- Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnl kidneys on U/S
- Drug-induced renal failure (NSAIDs, aminoglycosides)
Diagnosis[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:
- Serum Cr >1.5 mg/dL
- No improvement in renal function after halting diuretics AND admin of 1.5 L of plasma expander
- Proteinuria <500 mg/d
- No US 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
Treatment
- Vasoconstrictors
- Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
- Norepinepherine: 0.5-3mg/hr to increase MAP by 10mmHg
- Midrodrine: 7.5mg PO tid with Octreotide 100mcg sq
- Albumin: 1-1.5g/kg with one of above
- Other:
- TIPS, renal replacement therapy
Disposition
- 1-month survival: 50%
- 6-month survival: 20%
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