Hepatorenal Syndrome

From Anvita Health Wiki

Contents 1 Introduction 2 Etiology 3 Epidemiology 4 Pathology 5 Clinical-manifestations 6 Diagnostic-criteria 7 Laboratory 8 Management 9 More General Terms 10 Additional Terms 11 References

Introduction

• Severe renal hypoperfusion in patients with terminal hepatic cirrhosis. It may also develop with toxic agents that damage both the liver & kidney.

Etiology

• pre-renal hypoperfusion

• diuretics
• gastrointestinal bleeding
• paracentesis

• toxins

• carbon tetrachloride
• leptospirosis
• amyloidosis
• methoxyflurane

• vasculitis
• acute Wilson's disease

Epidemiology

• occurs in 40-50% of patients with terminal cirrhosis
• generally develops in a hospital setting
• some degree of functional renal impairment occurs in 1/2 of patients with cirrhosis & ascites [7]

Pathology

• liver failure resulting in renal hypoperfusion
• endothelin levels are 10 X normal
• leukotriene abnormalities suggested
• activated sympathetic nervous system
• activated renin- angiotensin axis
• severe vasoconstriction
• shunting of renal plasma flow from cortical to medullary segments
• transition to acute tubular necrosis is possible
• recovery occurs in about 10% of patients
• histology does NOT suggest primary renal disease

Clinical-manifestations

• ascites
• portal hypertension
• jaundice
• progressive azotemia & oliguria
• hypotension/ low blood pressure
• esophageal varices may be present

Diagnostic-criteria

• major criteria*

• acute or chronic liver disease with advanced hepatic failure & portal hypertension
• low glomerular filtration rate

• serum creatinine > 1.5 mg/dL
• creatinine clearance < 40 mL/min

• absence of

• treatment with nephrotoxic agents
• shock
• infection
• significant recent fluid loss

• no sustained improvement of renal function after discontinuation of diuretics & administration of 1.5 L of normal saline
• proteinuria < 500 mg/dL & no ultrasonographic evidence of obstruction or renal parenchymal disease

• minor criteria**

• urine volume < 500 mL/day
• urine Na+ < 10 meq/L
• urine osmolality > plasma osmolality
• urine RBC < 50/ hpf
• serum [Na+] < 130 meq/L
  

• * must be present for diagnosis ** based on criteria of low GFR & avid Na+ retention

Laboratory

• (in addition to above)
• hyponatremia
• hypoalbuminemia
• fractional excretion of Na+ ( FENA) < 1%
• high urine Na+ in the absence of diuretics suggests another diagnosis
• high plasma renin activity
• low plasma osmolality, high urine osmolality
• high serum potassium
• increased serum urea (>30 mg/dL)
• increased serum creatinine (>1.5 mg/dL)
• diminished GFR (<50 mL/min)

Management

• supportive measures

• discontinue potentially offending agents
• optimized central & renal hemodynamics
• volume expansion with albumin to assess component of prerenal azotemia
• low dose (renal) dopamine
• high doses of spironolactone ( Aldactone)
• norepinephrine may delay mortality [5]
• combination of octreotide + midodrine is often used
• terlipressin is used in Europe (not FDA-approved)

• surgery

• LaVeen shunt
• liver transplantation is treatment of choice

• prognosis: 3-6 month survival is ~ 20-40%

More General Terms

• syndrome

Additional Terms

• LaVeen shunt

References

1. Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 596
3. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, American College of Physicians, Philadelphia 1998, 2009
4. Medical Guidelines for Determining Prognosis in non-Cancer Diseases, 2nd edition, Stuart et al (eds), National Hospice Organization, Arlington, VA, 1996
5. Journal Watch 22(18):145, 2002 Duvoux C et al, Hepatology 36:374, 2002 Gines P & Guevara M, Hepatology 36:504, 2002
6. eMedicine: Hepatorenal Syndrome [1]
7. Montoliu S et al. Incidence and prognosis of different types of functional renal failure in cirrhotic patients with ascites. Clin Gastroenterol Hepatol 2010 Jul; 8:616. PMID: [2]

hepatorenal syndrome