Hepatorenal Syndrome

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 Diuretics withdrawn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