Hepatorenal syndrome

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Pathophysiology

Functional renal vasoconstriction leading to severe redxn in GFR with minimal renal histologic abnormalities


Diagnosis

Type 1: doubling of serum Cr to > 2.5mg/dl in < 2wk

Type 2: stable or less rapidly progressive course than Type 1

Type 1 & 2 both require*:

-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

-Abscence of current or recent rx with potentially nephrotoxic drugs

-Abscence of shock

-Abscence of renal parenchymal disease (urinary excretion of >500mg protein/d, >50 RBC/hpf, abnl kidneys on U/S)



DDx

-Hypovolemia-induced renal failure (GI bleed or fluid losses 2/2 diuretics, diarrhea most common)

-Parenchymal renal disease (proteinuria >500mg protein/d, >50 RBC/hpf or both; confirmed with renal biopsy)

-Drug-induced renal failure (current NSAIDs, aminoglycosides)


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%


Source

Adapted from NEJM vol 361 no 13 P. Gines

  • International Ascites Club criteria