Hepatorenal Syndrome
HRS
Definition: It is a form of renal impairment that occurs in the setting of acute or, more commonly chronic liver disease.
▲Cr, ▼ SPB (90 - 100 mmHg), mild to moderate hyponatremia (120 - 130 meQ/L), UNa <10 mEq/L is the typical presentation.
Common precipitating factors include systemic bacterial inf, SPB, overdiuresis, GIB, large-volume paracentesis without volume expansion can precipitate HRS in a cirrhotic patient.
Diagnosis: Major and minor diagnostic criteria:
Major criteria:
Low GFR, as indicated by Sr. Cr >1.5 mg/dL or 24-h Cr. Cl <40 mL/min
Absence of shock, ongoing bacterial inf., fluid losses, and current treatment with nephrotoxic drugs
No sustained improvement in renal function (decrease in Sr. Cr to 1.5 mg/dL or increase of 24-h Cr. Cl <40 mL/min) after diuretic withdrawal and expansion of plasma volume with 1.5 L of a plasma expander
Proteinuria <500 mg/dL and no US evidence of obstructive uropathy or parenchymal disease.
Additional criteria:
Urine volume <500 mL/d
Urine sodium <10 mEq/L
Uosm > Psom
Urine RBC <50/HPF
Sr. Na: <130 mEq/L
Note: All major criteria must be present for the diagnosis of HRS. Additional criteria are not necessary for the Dx but provide supportive evidence.
Type I HRS: Acute onset of rapid progressive (<2 wks) oliguric renal failure unresponsive to volume expansion. Initial Cr time doubles to a level of >2.5 mg/dL, or 50% reduction in the creatinine Cl to a level of <20 mL/min.
Type II HRS: Slow but relentless and often clinically manifests as diuretic-resistant ascites.
Tx: No clear treatment is established.
Systemic vasoconstrictors including vasopressin analogs (terlipressin), somatostatin analogs (octerotide), and alpha-adrenergic agonists (midodrine and norepinephrine) with plasma expansion have been shown to have a beneficial role in uncontrolled studies.
TIPS is potential alternative, but limited data is available.
HD may be indicated in Pts listed for liver transplantation.
In suitable candidates, liver transplantation may be curative.
Prognosis:
Without Tx, patients with type I HRS have a short-term prognosis, with death occurring within 2 to 3 months of onset. Pts with type II HRS have a median survival of approximately 6 months.