Hepatorenal syndrome: Difference between revisions

m (Rossdonaldson1 moved page Hepatorenal Syndrome to Hepatorenal syndrome)
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*Often heralded by the presence of SBP
*Often heralded by the presence of SBP
*Cause is unknown
*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)
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==
*Hypovolemia-induced renal failure
**[[GI bleed]]
**[[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]])


==Diagnosis==
==Diagnosis==
#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)
#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
##Abscence of current or recent rx with potentially nephrotoxic drugs
##Abscence of shock
##Abscence of renal parenchymal disease:


==DDx==
#Hypovolemia-induced renal failure
##GI bleed
##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==
#Vasoconstrictors
*[[Vasoconstrictors]]
##Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
**Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
##Norepi: 0.5-3mg/hr to increase MAP by 10mmHg
**[[Norepi]]: 0.5-3mg/hr to increase MAP by 10mmHg
##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:
*Other:
##TIPS, renal replacement therapy
**TIPS, renal replacement therapy


==Disposition==
==Disposition==
#1-month survival: 50%
*1-month survival: 50%
#6-month survival: 20%
*6-month survival: 20%


==Source==
==References==
*NEJM vol 361 no 13 P. Gines
*NEJM vol 361 no 13 P. Gines
*Tintinalli


[[Category:GI]]
[[Category:GI]]

Revision as of 19:37, 11 May 2015

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

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)

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

Diagnosis

Treatment

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

Disposition

  • 1-month survival: 50%
  • 6-month survival: 20%

References

  • NEJM vol 361 no 13 P. Gines