Hepatorenal syndrome: Difference between revisions
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==Background== | ==Background== | ||
*Acute renal failure in | *[[Acute renal failure]] in patient with normal kidneys in presence of acute/chronic hepatic failure | ||
*Often heralded by the presence of SBP | *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 | |||
**[[GI bleed]] | |||
**[[Diuretics]] | |||
**[[Diarrhea]] | |||
*Parenchymal renal disease | |||
**Urinary excretion of >500mg protein/d, >50 RBC/hpf, abnormal kidneys on U/S | |||
*Drug-induced renal failure ([[NSAIDs]], [[aminoglycosides]]) | |||
== | ==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]] | |||
*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]], [[hemodialysis|renal replacement therapy]] | |||
**Avoid diuretics and benzodiazepines | |||
**Discuss giving octreotide and/or midodrine with admitting physician | |||
==Disposition== | ==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 | *NEJM vol 361 no 13 P. Gines | ||
<references/> | |||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:Renal]] | |||
Latest revision as of 12:38, 24 April 2021
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