Updated: 12/20/2019

Hepatorenal Syndrome

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Snapshot
  • A 55-year-old man is admitted to the hospital due to fatigue, malaise, and weakness in the setting of poorly controlled cirrhosis. His symptoms began approximately one week prior to presentation, where he began to increase his alcohol intake after receiving news of the passing of his brother. Medical history is significant for cirrhosis due to chronic alcohol use disorder and hepatitis C infection. On hospital day 7, he was found to have a creatinine of 3.7 mg/dL (his creatinine was 1.2 mg/dL upon admission) and has significantly decreased urine output. He was not started on any nephrotoxic medications and post-renal obstruction has been ruled out. On physical exam, he is confused, has ascites, palmar erythema, jaundice, and gynecomastia. He is admitted into the intensive care unit to receive intravenous epinephrine and albumin.
Introduction
  • Clinical definition
    • kidney failure in the setting of liver disease
      • 2 types of hepatorenal syndrome (HPS)
        • type 1 HPS
          • severe form that has a rapid rise in serum creatinine (2-fold increase in < 2 weeks)
        • type 2 HPS
          • a less severe form that classically presents with ascites that is unresponsive to diuretics
  • Epidemiology
    • risk factors
      • acute or chronic liver disease
      • low mean arterial blood pressure
      • dilutional hyponatremia
      • urinary sodium retention (severe)
  • Etiology
    • can occur spontaneously
    • can be precipitated by spontaneous bacterial peritonitis (SBP)
  • Pathogenesis
    • portal hypertension triggers splanchnic arterial vasodilatation
      • this in turn decreases systemic vascular resistance which decreases renal perfusion
        • decreased renal perfusion leads to a decline in glomerular filtration rate (GFR) and sodium excretion
  • Associated conditions
    • portal hypertension secondary to
      • cirrhosis
      • severe alcoholic hepatitis
    • fulminant hepatic failure
  • Prognosis
    • depends on the type of hepatorenal syndrome
      • however, prognosis is typically poor without treatment
Presentation
  • Symptoms
    • fatigue
    • malaise
    • dysgeusia
  • Physical exam
    • stigmata of chronic liver disease such as
      • palmar erythema
      • spider nevi
      • scleral icterus
      • gynecomastia
      • hepatosplenomegaly
      • ascites
      • caput medusae
      • atrophic testes
    • oliguria may be seen
Studies
  • Labs - abnormalities secondary to pre-renal pathology  
    • progressive rise in serum creatinine
      • type 1 hepatorenal syndrome
        • a rapid rise in serum creatinine (2-fold increase in < 2 weeks)
      • type 2 hepatorenal syndrome
        • less severe
    • low sodium excretion rate
  • Making the diagnosis
    • a diagnosis of exclusion
Differential
  • Glomerulonephritis
  • Vasculitis
  • Diabetic nephropathy
  • Drug-induced nephrotoxicity
    • e.g., from aminoglycosides, diuretics, and contrast agents
Treatment
  • Medical
    • norepinephrine with albumin
      • indication
        • in critically ill patients with hepatorenal syndrome (HPS)
    • terlipressin with albumin or midodrine with octreotide and albumin
      • indication
        • in non-critically ill patients with HPS
        • the midodrine, octreotide, and albumin combination is typically given when terlipressin is not available
  • Operative
    • dialysis
      • indication
        • typically performed in patients who are waiting for liver transplantation
    • liver transplantation
      • indication
        • definitive treatment
Complications
  • Worsening liver failure that can result in
    • hepatic encephalopathy
    • jaundice
    • coagulopathy
 

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