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Hepatorenal Syndrome
Aka: Hepatorenal Syndrome, Urohepatic Syndrome, Renal Failure Secondary to Liver Disease, Hepatorenal Failure
- See Also
- Cirrhosis
- Cirrhotic Ascites
- Acute Kidney Injury
- Definitions
- Hepatorenal Syndrome
- Renal Failure due to Hepatic Cirrhosis
- Intrinsic renal disease absent
- Epidemiology
- Less common in Primary Biliary Cirrhosis
- Incidence in Cirrhosis with Ascites
- One year 18%
- Five years: 39%
- Pathophysiology
- Arterial vasodilation of splanchnic circulation
- Results in underfilling of arterial circulation
- Renin-Angiotensin System Activation
- Results in decreased renal perfusion due to renal vasconstriction
- Types
- Type I Hepatorenal Syndrome
- Associated with Spontaneous Bacterial Peritonitis
- Occurs in 25% of patients with SBP
- Rapid deterioration of Renal Function
- Serum Creatinine doubles to >2.5 mg/dl or
- Creatinine Clearance <20 ml/minute
- Survival
- Without treatment: <2 weeks (median)
- With Treatment: 10 weeks
- Type II Hepatorenal Syndrome
- Associated with Diuretic-resistant Ascites
- Renal Function declines moderately
- Serum Creatinine >1.5 mg/dl
- Survival: 3-6 months (median)
- Diagnosis
- Major Criteria
- Liver failure with Portal Hypertension
- Decreased Glomerular Filtration Rate (GFR)
- Serum Creatinine >1.5 mg/dl or
- Creatinine Clearance < 40 ml/min
- No alternative causes of Acute Renal Failure
- No Nephrotoxins
- No shock, Sepsis or Hypovolemia due to excessive diuresis
- Urine Protein <500 mg/dl
- No parenchymal renal disease by renal Ultrasound
- No ureteral obstruction by renal Ultrasound
- Renal Failure refractory to measures
- Diuretics withdrawn
- Volume expansion: 1.5 Liters Normal Saline
- Minor Criteria
- Urine Volume <500 ml/day
- Urine Sodium <10 meq/Liter
- Urine Osmolality increased over plasma osmolality
- Urine Red Blood Cells <50 per hpf
- Serum Sodium <130 mEq/L
- Labs
- Pan-culture for Sepsis
- Blood Culture
- Urine Culture
- Ascitic fluid culture (see Paracentesis)
- Urinalysis
- Evaluate for Hematuria and Proteinuria
- Imaging
- Renal Ultrasound
- Exclude renovascular disease
- Exclude Hydronephrosis
- Management
- Consider Intensive Care admission for close monitoring of fluids, Electrolytes, hemodynamic status
- Avoid Nephrotoxins and stop contributing factors
- Stop Diuretics
- Stop Beta Blockers
- Stop NSAIDs
- Stop Angiotensin Converting Enzyme Inhibitors (ACE Inhibitors)
- Stop Angiotensin Receptor Blockers
- Stop vasodilators
- Albumin replacement
- Administer 1 g/kg/day (maximum dose of 100 g/day) for 2 days
- May continue albumin at 20 to 40 g/day as needed for Hypotension requiring Vasopressors
- Vasopressors
- Target: Increase Mean Arterial Pressure >15mmHg
- Preparations
- Norepinephrine OR
- Midodrine orally with Octreotide IV
- Other management
- Consider Hemodialysis
- Consider Transjugular Intrahepatic Portosystemic Shunt (TIPS)
- Consult for liver transplant
- References
- Swencki (2015) Crit Dec Emerg Med 29(11):2-10
- Keating (2022) Am Fam Physician 105(4): 412-20 [PubMed]