Difference between revisions of "Hepatorenal syndrome"

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==Pathophysiology==
+
==Background==
Functional renal vasoconstriction leading to severe redxn in GFR with minimal renal histologic abnormalities
+
*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
  
 
==Diagnosis==
 
==Diagnosis==
#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 Cr over a 2-week period
#Type 1 & 2 both require^:
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##Progressive oliguria
 +
#Type 2
 +
##Gradual impairment in renal function (that may not advance beyond moderate)
 +
#Type 1 & 2 both require:
 
##Cr >1.5mg/dl
 
##Cr >1.5mg/dl
##Cr NOT reduced below 1.5mg/dl with administration of albumin (1g/kg) and after a minimum of 2 days off diuretics  
+
##Cr not reduced below 1.5 w/ albumin (1g/kg) and after minimum of 2 days off diuretics  
 
##Abscence of current or recent rx with potentially nephrotoxic drugs
 
##Abscence of current or recent rx with potentially nephrotoxic drugs
 
##Abscence of shock
 
##Abscence of shock
##Abscence of renal parenchymal disease (urinary excretion of >500mg protein/d, >50 RBC/hpf, abnl kidneys on U/S)
+
##Abscence of renal parenchymal disease:
  
 
==DDx==
 
==DDx==
#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
 +
##Diarrhea
 +
#Parenchymal renal disease
 +
##Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnl kidneys on U/S
 +
#Drug-induced renal failure (NSAIDs, aminoglycosides)
  
 
==Treatment==
 
==Treatment==
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##Midrodrine: 7.5mg PO tid with Octreotide 100mcg sq
 
##Midrodrine: 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: TIPS, renal replacement therapy
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#Other:
 +
##TIPS, renal replacement therapy
  
 
==Disposition==
 
==Disposition==
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==Source==
 
==Source==
Adapted from NEJM vol 361 no 13 P. Gines
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*NEJM vol 361 no 13 P. Gines
 
+
*Tintinalli
^International Ascites Club criteria
 
  
 
[[Category:GI]]
 
[[Category:GI]]

Revision as of 06:06, 1 August 2011

Background

  • 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

Diagnosis

  1. Type 1
    1. Doubling of serum Cr over a 2-week period
    2. Progressive oliguria
  2. Type 2
    1. Gradual impairment in renal function (that may not advance beyond moderate)
  3. Type 1 & 2 both require:
    1. Cr >1.5mg/dl
    2. Cr not reduced below 1.5 w/ albumin (1g/kg) and after minimum of 2 days off diuretics
    3. Abscence of current or recent rx with potentially nephrotoxic drugs
    4. Abscence of shock
    5. Abscence of renal parenchymal disease:

DDx

  1. Hypovolemia-induced renal failure
    1. GI bleed
    2. Diuretics
    3. Diarrhea
  2. Parenchymal renal disease
    1. Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnl kidneys on U/S
  3. Drug-induced renal failure (NSAIDs, aminoglycosides)

Treatment

  1. Vasoconstrictors
    1. Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
    2. Norepi: 0.5-3mg/hr to increase MAP by 10mmHg
    3. Midrodrine: 7.5mg PO tid with Octreotide 100mcg sq
  2. Albumin: 1-1.5g/kg with one of above
  3. Other:
    1. TIPS, renal replacement therapy

Disposition

  1. 1-month survival: 50%
  2. 6-month survival: 20%

Source

  • NEJM vol 361 no 13 P. Gines
  • Tintinalli