Hepatorenal syndrome

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