Hepatorenal syndrome: Difference between revisions
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==Background== | ==Background== | ||
*[[Acute renal failure]] in patient with normal kidneys in presence of acute/chronic hepatic failure | |||
*Often heralded by the presence of [[SBP]] | *[[Special:MyLanguage/Acute renal failure|Acute renal failure]] in patient with normal kidneys in presence of acute/chronic hepatic failure | ||
*Often heralded by the presence of [[Special:MyLanguage/SBP|SBP]] | |||
* Arterial vasodilatation in the splanchnic circulation, which is triggered by portal hypertension | * Arterial vasodilatation in the splanchnic circulation, which is triggered by portal hypertension | ||
*Diagnosis of exclusion | *Diagnosis of exclusion | ||
==Clinical Features== | ==Clinical Features== | ||
*Type 1 | *Type 1 | ||
**Doubling of serum creatinine over a 2-week period | **Doubling of serum creatinine over a 2-week period | ||
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*Type 2 | *Type 2 | ||
**Gradual impairment in renal function (that may not advance beyond moderate) | **Gradual impairment in renal function (that may not advance beyond moderate) | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*Hypovolemia-induced renal failure | *Hypovolemia-induced renal failure | ||
**[[GI bleed]] | **[[Special:MyLanguage/GI bleed|GI bleed]] | ||
**[[Diuretics]] | **[[Special:MyLanguage/Diuretics|Diuretics]] | ||
**[[Diarrhea]] | **[[Special:MyLanguage/Diarrhea|Diarrhea]] | ||
*Parenchymal renal disease | *Parenchymal renal disease | ||
**Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnormal kidneys on U/S | **Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnormal kidneys on U/S | ||
*Drug-induced renal failure ([[NSAIDs]], [[aminoglycosides]]) | *Drug-induced renal failure ([[Special:MyLanguage/NSAIDs|NSAIDs]], [[Special:MyLanguage/aminoglycosides|aminoglycosides]]) | ||
==Evaluation<ref>Deepika D et al. Hepatorenal Syndrome Workup. Dec 27, 2015. http://emedicine.medscape.com/article/178208-workup#showall</ref>== | ==Evaluation<ref>Deepika D et al. Hepatorenal Syndrome Workup. Dec 27, 2015. http://emedicine.medscape.com/article/178208-workup#showall</ref>== | ||
*[[Ultrasound: Abdomen|Abdominal US]] | *[[Ultrasound: Abdomen|Abdominal US]] | ||
*Diagnostic [[paracentesis]] | *Diagnostic [[Special:MyLanguage/paracentesis|paracentesis]] | ||
*Ascites fluid cultures and analysis | *Ascites fluid cultures and analysis | ||
*Labs: | *Labs: | ||
**CBC with diff | **CBC with diff | ||
**BMP | **BMP | ||
**[[LFTs]] | **[[Special:MyLanguage/LFTs|LFTs]] | ||
**Blood cultures | **Blood cultures | ||
**[[Urinalysis]] | **[[Special:MyLanguage/Urinalysis|Urinalysis]] | ||
**Urine electrolytes and osmolality | **Urine electrolytes and osmolality | ||
**Consultants: alpha-fetoprotein, cryoglobulins | **Consultants: alpha-fetoprotein, cryoglobulins | ||
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**Serum creatinine >1.5mg/dL | **Serum creatinine >1.5mg/dL | ||
**No improvement in renal function after halting diuretics AND admin of 1.5 L of plasma expander | **No improvement in renal function after halting diuretics AND admin of 1.5 L of plasma expander | ||
**[[Proteinuria]] <500mg/d | **[[Special:MyLanguage/Proteinuria|Proteinuria]] <500mg/d | ||
**No [[ultrasound]] evidence of obstructive uropathy or renal parenchymal disease | **No [[Special:MyLanguage/ultrasound|ultrasound]] evidence of obstructive uropathy or renal parenchymal disease | ||
**Absence of shock, bacterial infection, hypovolemia, nephrotoxic meds | **Absence of shock, bacterial infection, hypovolemia, nephrotoxic meds | ||
*Supporting criteria not required for diagnosis: | *Supporting criteria not required for diagnosis: | ||
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**Urine RBC <50 cells/hpf | **Urine RBC <50 cells/hpf | ||
**Serum sodium <130 mEq/L | **Serum sodium <130 mEq/L | ||
==Management== | ==Management== | ||
*[[Vasopressors]] | |||
*[[Special:MyLanguage/Vasopressors|Vasopressors]] | |||
**Terlipressin: 0.5-1mg q 4-6 IV us 5-15d | **Terlipressin: 0.5-1mg q 4-6 IV us 5-15d | ||
**[[Norepinephrine]]: 0.5-3mg/hr to increase MAP by 10mmHg | **[[Special:MyLanguage/Norepinephrine|Norepinephrine]]: 0.5-3mg/hr to increase MAP by 10mmHg | ||
**[[Midodrine]]: 7.5mg PO tid with Octreotide 100mcg sq | **[[Special:MyLanguage/Midodrine|Midodrine]]: 7.5mg PO tid with Octreotide 100mcg sq | ||
*Albumin: 1-1.5g/kg with one of above | *Albumin: 1-1.5g/kg with one of above | ||
*Other: | *Other: | ||
**[[TIPS]], [[hemodialysis|renal replacement therapy]] | **[[Special:MyLanguage/TIPS|TIPS]], [[Special:MyLanguage/hemodialysis|renal replacement therapy]] | ||
**Avoid diuretics and benzodiazepines | **Avoid diuretics and benzodiazepines | ||
**Discuss giving octreotide and/or midodrine with admitting physician | **Discuss giving octreotide and/or midodrine with admitting physician | ||
==Disposition== | ==Disposition== | ||
*1-month survival: 50% | *1-month survival: 50% | ||
*6-month survival: 20% | *6-month survival: 20% | ||
*Should be evaluated at liver transplant center | *Should be evaluated at liver transplant center | ||
*May require TIPS, vasoconstrictors as bridge to transplant | *May require TIPS, vasoconstrictors as bridge to transplant | ||
==See Also== | ==See Also== | ||
==References== | ==References== | ||
*NEJM vol 361 no 13 P. Gines | *NEJM vol 361 no 13 P. Gines | ||
<references/> | <references/> | ||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:Renal]] | [[Category:Renal]] | ||
</translate> | |||
Latest revision as of 23:04, 4 January 2026
Background
- Acute renal failure in patient with normal kidneys in presence of acute/chronic hepatic failure
- Often heralded by the presence of SBP
- Arterial vasodilatation in the splanchnic circulation, which is triggered by portal hypertension
- Diagnosis of exclusion
Clinical Features
- Type 1
- Doubling of serum creatinine over a 2-week period
- Progressive oliguria
- Type 2
- Gradual impairment in renal function (that may not advance beyond moderate)
Differential Diagnosis
- Hypovolemia-induced renal failure
- Parenchymal renal disease
- Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnormal kidneys on U/S
- Drug-induced renal failure (NSAIDs, aminoglycosides)
Evaluation[1]
- Abdominal US
- Diagnostic paracentesis
- Ascites fluid cultures and analysis
- Labs:
- CBC with diff
- BMP
- LFTs
- Blood cultures
- Urinalysis
- Urine electrolytes and osmolality
- Consultants: alpha-fetoprotein, cryoglobulins
- All major criteria must be met for diagnosis for both HRS types 1 and 2:
- Serum creatinine >1.5mg/dL
- No improvement in renal function after halting diuretics AND admin of 1.5 L of plasma expander
- Proteinuria <500mg/d
- No ultrasound evidence of obstructive uropathy or renal parenchymal disease
- Absence of shock, bacterial infection, hypovolemia, nephrotoxic meds
- Supporting criteria not required for diagnosis:
- Uop <500 cc/day
- Urine sodium <10 mEq/L
- Urine osmolality > plasma osmolality
- Urine RBC <50 cells/hpf
- Serum sodium <130 mEq/L
Management
- Vasopressors
- Terlipressin: 0.5-1mg q 4-6 IV us 5-15d
- Norepinephrine: 0.5-3mg/hr to increase MAP by 10mmHg
- Midodrine: 7.5mg PO tid with Octreotide 100mcg sq
- Albumin: 1-1.5g/kg with one of above
- Other:
- TIPS, renal replacement therapy
- Avoid diuretics and benzodiazepines
- Discuss giving octreotide and/or midodrine with admitting physician
Disposition
- 1-month survival: 50%
- 6-month survival: 20%
- Should be evaluated at liver transplant center
- May require TIPS, vasoconstrictors as bridge to transplant
See Also
References
- NEJM vol 361 no 13 P. Gines
- ↑ Deepika D et al. Hepatorenal Syndrome Workup. Dec 27, 2015. http://emedicine.medscape.com/article/178208-workup#showall