Difference between revisions of "Hepatorenal syndrome"

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==Pathophysiology==
+
==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)
  
Functional renal vasoconstriction leading to severe redxn in GFR with minimal renal histologic abnormalities
+
==Differential Diagnosis==
 +
*Hypovolemia-induced renal failure
 +
**[[GI bleed]]
 +
**[[Diuretics]]
 +
**[[Diarrhea]]
 +
*Parenchymal renal disease
 +
**Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnormal kidneys on U/S
 +
*Drug-induced renal failure ([[NSAIDs]], [[aminoglycosides]])
  
+
==Evaluation<ref>Deepika D et al. Hepatorenal Syndrome Workup. Dec 27, 2015. http://emedicine.medscape.com/article/178208-workup#showall</ref>==
 +
*[[Ultrasound: Abdomen|Abdominal US]]
 +
*Diagnostic [[paracentesis]]
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*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
  
==Diagnosis==
+
==Management==
 
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*[[Vasopressors]]
 
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**Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
Type 1: doubling of serum Cr to > 2.5mg/dl in < 2wk
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**[[Norepinephrine]]: 0.5-3mg/hr to increase MAP by 10mmHg
 
+
**[[Midodrine]]: 7.5mg PO tid with Octreotide 100mcg sq
Type 2: stable or less rapidly progressive course than Type 1
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*Albumin: 1-1.5g/kg with one of above
 
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*Other:
Type 1 & 2 both require*:
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**[[TIPS]], [[hemodialysis|renal replacement therapy]]
 
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**Avoid diuretics and benzodiazepines
-Cr >1.5mg/dl
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**Discuss giving octreotide and/or midodrine with admitting physician
 
 
-Cr NOT reduced below 1.5mg/dl with administration of albumin (1g/kg) and after a minimum of 2 days off diuretics
 
 
 
-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==
 
 
 
 
 
-Hypovolemia-induced renal failure (GI bleed or fluid losses 2/2 diuretics, diarrhea most common)
 
 
 
-Parenchymal renal disease (proteinuria >500mg protein/d, >50 RBC/hpf or both; confirmed with renal biopsy)
 
 
 
-Drug-induced renal failure (current NSAIDs, aminoglycosides)
 
 
 
 
 
 
==Treatment==
 
 
 
 
 
Vasoconstrictors
 
 
 
    -Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
 
 
 
    -Norepi: 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==
 
==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==
  
1-month survival: 50%
+
==References==
 
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*NEJM vol 361 no 13 P. Gines
6-month survival: 20%
+
<references/>
 
 
 
 
 
==Source==
 
 
 
 
 
Adapted from NEJM vol 361 no 13 P. Gines
 
 
 
*International Ascites Club criteria
 
 
 
 
 
 
 
 
 
 
[[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