Difference between revisions of "Hepatorenal syndrome"

(Management)
 
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==Pathophysiology==
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==Background==
Functional renal vasoconstriction leading to severe redxn in GFR with minimal renal histologic abnormalities
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*[[Acute renal failure]] in patient with normal kidneys in presence of acute/chronic hepatic failure
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*Often heralded by the presence of [[SBP]]
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* Arterial vasodilatation in the splanchnic circulation, which is triggered by portal hypertension
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*Diagnosis of exclusion
  
==Diagnosis==
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==Clinical Features==
#Type 1: doubling of serum Cr to > 2.5mg/dl in < 2wk
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*Type 1
#Type 2: stable or less rapidly progressive course than Type 1
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**Doubling of serum creatinine over a 2-week period
#Type 1 & 2 both require^:
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**Progressive oliguria
##Cr >1.5mg/dl
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*Type 2
##Cr NOT reduced below 1.5mg/dl with administration of albumin (1g/kg) and after a minimum of 2 days off diuretics
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**Gradual impairment in renal function (that may not advance beyond moderate)
##Abscence of current or recent rx with potentially nephrotoxic drugs
 
##Abscence of shock
 
##Abscence of renal parenchymal disease (urinary excretion of >500mg protein/d, >50 RBC/hpf, abnl kidneys on U/S)
 
  
==DDx==
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==Differential Diagnosis==
#Hypovolemia-induced renal failure (GI bleed or fluid losses 2/2 diuretics, diarrhea most common)
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*Hypovolemia-induced renal failure
#Parenchymal renal disease (proteinuria >500mg protein/d, >50 RBC/hpf or both; confirmed with renal biopsy)
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**[[GI bleed]]
#Drug-induced renal failure (current NSAIDs, aminoglycosides)
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**[[Diuretics]]
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**[[Diarrhea]]
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*Parenchymal renal disease
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**Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnormal kidneys on U/S
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*Drug-induced renal failure ([[NSAIDs]], [[aminoglycosides]])
  
==Treatment==
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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>==
#Vasoconstrictors
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*[[Ultrasound: Abdomen|Abdominal US]]
##Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
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*Diagnostic [[paracentesis]]
##Norepi: 0.5-3mg/hr to increase MAP by 10mmHg
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*Ascites fluid cultures and analysis
##Midrodrine: 7.5mg PO tid with Octreotide 100mcg sq
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*Labs:
#Albumin: 1-1.5g/kg with one of above
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**CBC with diff
#Other: TIPS, renal replacement therapy
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**BMP
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**[[LFTs]]
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**Blood cultures
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**[[Urinalysis]]
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**Urine electrolytes and osmolality
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**Consultants: alpha-fetoprotein, cryoglobulins
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*All major criteria must be met for diagnosis for both HRS types 1 and 2:
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**Serum creatinine >1.5mg/dL
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**No improvement in renal function after halting diuretics AND admin of 1.5 L of plasma expander
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**[[Proteinuria]] <500mg/d
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**No [[ultrasound]] evidence of obstructive uropathy or renal parenchymal disease
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**Absence of shock, bacterial infection, hypovolemia, nephrotoxic meds
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*Supporting criteria not required for diagnosis:
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**Uop <500 cc/day
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**Urine sodium <10 mEq/L
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**Urine osmolality > plasma osmolality
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**Urine RBC <50 cells/hpf
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**Serum sodium <130 mEq/L
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==Management==
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*[[Vasopressors]]
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**Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
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**[[Norepinephrine]]: 0.5-3mg/hr to increase MAP by 10mmHg
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**[[Midodrine]]: 7.5mg PO tid with Octreotide 100mcg sq
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*Albumin: 1-1.5g/kg with one of above
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*Other:
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**[[TIPS]], [[hemodialysis|renal replacement therapy]]
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**Avoid diuretics and benzodiazepines
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**Discuss giving octreotide and/or midodrine with admitting physician
  
 
==Disposition==
 
==Disposition==
#1-month survival: 50%
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*1-month survival: 50%
#6-month survival: 20%
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*6-month survival: 20%
 
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*Should be evaluated at liver transplant center
==Source==
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*May require TIPS, vasoconstrictors as bridge to transplant
Adapted from NEJM vol 361 no 13 P. Gines
 
  
^International Ascites Club criteria
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==See Also==
  
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==References==
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*NEJM vol 361 no 13 P. Gines
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<references/>
 
[[Category:GI]]
 
[[Category:GI]]
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[[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