Hepatorenal syndrome

Thank you Dr. Vega for this Morning Report

Hepatorenal Syndrome

Patient usually has history of cirrhosis, hepatitis, or can be acute in setting of ATN or recurrent hospitalizations with nephrotoxic agents.

Types of hepatorenal syndrome

Type I:

Rapid/progressive impairment of renal function with initial serum creatinine level doubled from baseline or a level higher than 2.5 mg/dl or a 50% reduction of the initial 24-hour creatinine clearance to a level lower than 20 ml/minute in less than 2 weeks.

Type II:

Impairment in renal function (serum creatinine 41.5 mg/dl) that does not meet the criteria of type I

Treatment should vary based on criteria but clinical situation may warrant the same treatment despite type 1 or 2.

So the patient has cirrhosis and the Cr is elevated, now what…? How do I know if its hepatorenal syndrome (HRS)?

Major criteria

1. Low glomerular filtration rate, as indicated by serum creatinine > 1.5 mg/dl or 24-hour creatinine clearance < 40 ml/minute
2. Absence of shock, ongoing bacterial infection, fluid losses, and current treatment with nephrotoxic drugs
3. No sustained improvement in renal function (decrease in serum creatinine to ≤ 1.5 mg/dl or creatinine clearance ≥ 40 ml/minute) following diuretic withdrawal and expansion of plasma volume
4. Proteinuria < 500 mg/day and no ultrasonographic evidence of obstructive uropathy or parenchymal renal disease

Additional criteria

1. Urine volume < 500 ml/day
2. Urine sodium < 10 mEq/l
3. Urine osmolality > plasma osmolality
4. Urine red blood cells < 50 per high-power field
5. Serum sodium concentration < 130 mEq/l

All major criteria must be present for the diagnosis of hepatorenal syndrome. Additional criteria are not necessary for the diagnosis but provide supportive evidence.

***In addition to criteria and disposition, there has to be a risk stratification for these patients and one way is to use the MELD score that takes into account factors such as dialysis > 2 x/week, Cr, bilirubin, and INR. ***

Treatment

Critically ill vs not critically ill

The main stay/goal of therapy is to provide adequate renal perfusion.

Critically ill –

Norepinephrine infusion in combination with albumin at 0.5-3mg/hr

OR

Vasopressin 0.01 units/min titrating upward to increase MAP

The goal is usually to increase MAP by 10mmHg given that these patients are normally under perfused… with a goal to trying to provide renal perfusion. 

Albumin should be given at 1g/kg (max 100g) daily for 2 days. 2 days are used to determine failure of medical therapy and need for transjugular intrahepatic portosystemic shunt (TIPS).

Not critically ill-

Midodrine oral 7.5 mg q8hr titrate up to 15 mg PO q8hr PLUS

Octreotide continuous infusion 50 mcg/hr or 100-200mcg TID

Albumin 1g/kg (max dose of 100mg daily).

If this treatment does not aid in improving renal function (increasing urine output, lowering Cr), TIPS is indicated.

Disposition

– Floor vs ICU

Any patient in whom hepatic renal syndrome is considered should have an critical care medicine consult.

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Brian

Kings County Hospital | SUNY Downstate Emergency Medicine Resident -Clinical Monster Webmaster

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