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.