Difference between revisions of "Hepatorenal syndrome"

(Diagnosis)
(Management)
 
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==Background==
 
==Background==
*Acute renal failure in pt w/ nl 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==
 
*Type 1
 
*Type 1
**Doubling of serum Cr over a 2-week period
+
**Doubling of serum creatinine over a 2-week period
 
**Progressive oliguria
 
**Progressive oliguria
 
*Type 2
 
*Type 2
 
**Gradual impairment in renal function (that may not advance beyond moderate)
 
**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==
 
==Differential Diagnosis==
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**[[Diarrhea]]
 
**[[Diarrhea]]
 
*Parenchymal renal disease
 
*Parenchymal renal disease
**Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnl kidneys on U/S
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**Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnormal kidneys on U/S
 
*Drug-induced renal failure ([[NSAIDs]], [[aminoglycosides]])
 
*Drug-induced renal failure ([[NSAIDs]], [[aminoglycosides]])
  
==Diagnosis<ref>Deepika D et al. Hepatorenal Syndrome Workup. Dec 27, 2015. http://emedicine.medscape.com/article/178208-workup#showall</ref>==
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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>==
*Abdominal US
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*[[Ultrasound: Abdomen|Abdominal US]]
*Diagnostic paracentesis
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*Diagnostic [[paracentesis]]
 
*Ascites fluid cultures and analysis
 
*Ascites fluid cultures and analysis
 
*Labs:
 
*Labs:
 
**CBC with diff
 
**CBC with diff
 
**BMP
 
**BMP
**LFTs
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**[[LFTs]]
 
**Blood cultures
 
**Blood cultures
**Urinalysis
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**[[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:
+
*All major criteria must be met for diagnosis for both HRS types 1 and 2:
**Serum Cr >1.5 mg/dL
+
**Serum creatinine >1.5mg/dL
 
**No improvement in renal function after halting diuretics AND admin of 1.5 L of plasma expander
 
**No improvement in renal function after halting diuretics AND admin of 1.5 L of plasma expander
**Proteinuria <500 mg/d
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**[[Proteinuria]] <500mg/d
**No US 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
 
*Supporting criteria not required for diagnosis:
 
*Supporting criteria not required for diagnosis:
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**Serum sodium <130 mEq/L
 
**Serum sodium <130 mEq/L
  
==Treatment==
+
==Management==
*[[Vasoconstrictors]]
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*[[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
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**[[Norepinephrine]]: 0.5-3mg/hr to increase MAP by 10mmHg
**Midrodrine: 7.5mg PO tid with Octreotide 100mcg sq
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**[[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
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**[[TIPS]], [[hemodialysis|renal replacement therapy]]
 +
**Avoid diuretics and benzodiazepines
 +
**Discuss giving octreotide and/or midodrine with admitting physician
  
 
==Disposition==
 
==Disposition==
 
*1-month survival: 50%
 
*1-month survival: 50%
 
*6-month survival: 20%
 
*6-month survival: 20%
 +
*Should be evaluated at liver transplant center
 +
*May require TIPS, vasoconstrictors as bridge to transplant
  
 
==See Also==
 
==See Also==
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==References==
 
==References==
 
*NEJM vol 361 no 13 P. Gines
 
*NEJM vol 361 no 13 P. Gines
 
+
<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