Difference between revisions of "Hepatorenal syndrome"

(Text replacement - " L " to " left ")
(Management)
 
(10 intermediate revisions by 6 users not shown)
Line 2: Line 2:
 
*[[Acute renal failure]] in patient with normal kidneys in presence of acute/chronic hepatic failure  
 
*[[Acute renal failure]] in patient with normal kidneys in presence of acute/chronic hepatic failure  
 
*Often heralded by the presence of [[SBP]]
 
*Often heralded by the presence of [[SBP]]
*Cause is unknown
+
* Arterial vasodilatation in the splanchnic circulation, which is triggered by portal hypertension
 +
*Diagnosis of exclusion
  
 
==Clinical Features==
 
==Clinical Features==
Line 21: Line 22:
  
 
==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]]
 
**Urine electrolytes and osmolality
 
**Urine electrolytes and osmolality
 
**Consultants: alpha-fetoprotein, cryoglobulins
 
**Consultants: alpha-fetoprotein, cryoglobulins
 
*All major criteria must be met for diagnosis for both HRS types 1 and 2:
 
*All major criteria must be met for diagnosis for both HRS types 1 and 2:
 
**Serum creatinine >1.5mg/dL
 
**Serum creatinine >1.5mg/dL
**No improvement in renal function after halting diuretics AND admin of 1.5 left of plasma expander
+
**No improvement in renal function after halting diuretics AND admin of 1.5 L of plasma expander
**Proteinuria <500mg/d
+
**[[Proteinuria]] <500mg/d
 
**No [[ultrasound]] evidence of obstructive uropathy or renal parenchymal disease
 
**No [[ultrasound]] evidence of obstructive uropathy or renal parenchymal disease
 
**Absence of shock, bacterial infection, hypovolemia, nephrotoxic meds
 
**Absence of shock, bacterial infection, hypovolemia, nephrotoxic meds
Line 46: Line 47:
  
 
==Management==
 
==Management==
*[[Vasoconstrictors]]
+
*[[Vasopressors]]
 
**Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
 
**Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
**[[Norepinepherine]]: 0.5-3mg/hr to increase MAP by 10mmHg
+
**[[Norepinephrine]]: 0.5-3mg/hr to increase MAP by 10mmHg
**Midrodrine: 7.5mg PO tid with Octreotide 100mcg sq
+
**[[Midodrine]]: 7.5mg PO tid with Octreotide 100mcg sq
 
*Albumin: 1-1.5g/kg with one of above
 
*Albumin: 1-1.5g/kg with one of above
 
*Other:
 
*Other:
**TIPS, renal replacement therapy
+
**[[TIPS]], [[hemodialysis|renal replacement therapy]]
 +
**Avoid diuretics and benzodiazepines
 +
**Discuss giving octreotide and/or midodrine with admitting physician
  
 
==Disposition==
 
==Disposition==
Line 66: Line 69:
 
<references/>  
 
<references/>  
 
[[Category:GI]]
 
[[Category:GI]]
 +
[[Category:Renal]]

Latest revision as of 12:38, 24 April 2021

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

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:

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