Gastroenterology Book

Cirrhosis

  • Hepatorenal Syndrome

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Hepatorenal Syndrome

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  1. See Also
    1. Cirrhosis
  2. Definition
    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
    2. Results in underfilling of arterial circulation
  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 or Sepsis
        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 Diuretics withdrawn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. Management
    1. Hemodialysis
    2. Avoid Nephrotoxins
    3. Midodrine PO with Octreotide IV
      1. Target: Increase Mean Arterial PrEssure >15mmHg
    4. Dopamine 2-4 mcg/kg/min IV

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