Hepatorenal syndrome

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Pathophysiology

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

Diagnosis

  1. Type 1: doubling of serum Cr to > 2.5mg/dl in < 2wk
  2. Type 2: stable or less rapidly progressive course than Type 1
  3. Type 1 & 2 both require^:
    1. Cr >1.5mg/dl
    2. Cr NOT reduced below 1.5mg/dl with administration of albumin (1g/kg) and after a 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 (urinary excretion of >500mg protein/d, >50 RBC/hpf, abnl kidneys on U/S)

DDx

  1. Hypovolemia-induced renal failure (GI bleed or fluid losses 2/2 diuretics, diarrhea most common)
  2. Parenchymal renal disease (proteinuria >500mg protein/d, >50 RBC/hpf or both; confirmed with renal biopsy)
  3. Drug-induced renal failure (current 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: TIPS, renal replacement therapy

Disposition

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

Source

Adapted from NEJM vol 361 no 13 P. Gines

^International Ascites Club criteria