Hepatorenal syndrome: Difference between revisions

(Text replacement - "==Treatment==" to "==Management==")
 
(21 intermediate revisions by 6 users not shown)
Line 1: Line 1:
==Background==
==Background==
*Acute renal failure in patient 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
Line 17: Line 18:
**[[Diarrhea]]
**[[Diarrhea]]
*Parenchymal renal disease
*Parenchymal renal disease
**Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnl kidneys on U/S
**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>==
==Evaluation<ref>Deepika D et al. Hepatorenal Syndrome Workup. Dec 27, 2015. http://emedicine.medscape.com/article/178208-workup#showall</ref>==
*Abdominal US
*[[Ultrasound: Abdomen|Abdominal US]]
*Diagnostic paracentesis
*Diagnostic [[paracentesis]]
*Ascites fluid cultures and analysis
*Ascites fluid cultures and analysis
*Labs:
*Labs:
**CBC with diff
**CBC with diff
**BMP
**BMP
**LFTs
**[[LFTs]]
**Blood cultures
**Blood cultures
**Urinalysis
**[[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 for both HRS types 1 and 2:
*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
**[[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:
Line 46: Line 47:


==Management==
==Management==
*[[Vasoconstrictors]]
*[[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
**[[Norepinephrine]]: 0.5-3mg/hr to increase MAP by 10mmHg
**Midrodrine: 7.5mg PO tid with Octreotide 100mcg sq
**[[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
**[[TIPS]], [[hemodialysis|renal replacement therapy]]
**Avoid diuretics and benzodiazepines
**Discuss giving octreotide and/or midodrine with admitting physician


==Disposition==
==Disposition==
Line 66: Line 69:
<references/>  
<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