Hepatorenal syndrome: Difference between revisions

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*[[Acute renal failure]] in patient with normal 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
*Diagnosis of exclusion



Revision as of 23:31, 17 February 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

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