Difference between revisions of "Hepatorenal syndrome"

Line 10: Line 10:
*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==

Revision as of 19:20, 11 January 2016


  • Acute renal failure in pt w/ nl 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 Cr over a 2-week period
    • Progressive oliguria
  • Type 2
    • Gradual impairment in renal function (that may not advance beyond moderate)

Differential Diagnosis


  • 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:
    • Serum Cr >1.5 mg/dL
    • No improvement in renal function after halting diuretics AND admin of 1.5 L of plasma expander
    • Proteinuria <500 mg/d
    • No US 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


  • Vasoconstrictors
    • Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
    • Norepinepherine: 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


  • 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


  • 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