Difference between revisions of "Hepatorenal syndrome"

(Management)
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==Evaluation<ref>Deepika D et al. Hepatorenal Syndrome Workup. Dec 27, 2015. http://emedicine.medscape.com/article/178208-workup#showall</ref>==
 
==Evaluation<ref>Deepika D et al. Hepatorenal Syndrome Workup. Dec 27, 2015. http://emedicine.medscape.com/article/178208-workup#showall</ref>==
*Abdominal US
+
*[[Ultrasound: Abdomen|Abdominal US]]
*Diagnostic paracentesis
+
*Diagnostic [[paracentesis]]
 
*Ascites fluid cultures and analysis
 
*Ascites fluid cultures and analysis
 
*Labs:
 
*Labs:
 
**CBC with diff
 
**CBC with diff
 
**BMP
 
**BMP
**LFTs
+
**[[LFTs]]
 
**Blood cultures
 
**Blood cultures
 
**[[Urinalysis]]
 
**[[Urinalysis]]

Revision as of 21:13, 29 September 2019

Background

  • Acute renal failure in patient with normal 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 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:
    • TIPS, renal replacement therapy

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