Renal

Hepatorenal Syndrome

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Hepatorenal Syndrome

  • Definition
  1. Renal Failure due to Hepatic Cirrhosis
  2. Intrinsic renal disease absent
  • Epidemiology
  1. Less common in Primary Biliary Cirrhosis
  2. Incidence in Cirrhosis with Ascites
    1. One year 18%
    2. Five years: 39%
  • 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
  • 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)
  • 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 Diuretics withdrawn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
  • 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
  • Imaging
  1. Renal Ultrasound
    1. Exclude renovascular disease
    2. Exclude Hydronephrosis
  • Management
  1. Consider intensive care admission for close monitoring of fluids, electrolytes, hemodynamic status
  2. Avoid Nephrotoxins
  3. Albumin replacement
  4. Vasoconstrictors
    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. Consult for liver transplant
  • References
  1. Swencki (2015) Crit Dec Emerg Med 29(11):2-10