Synopsis of Hepatorenal Syndrome

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Synopsis of Hepatorenal Syndrome

• Wang, Tzong-Luen, MD, PhD

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HRS

• Aggressive form of ARF that frequently
  complicates hepatic failure due to advanced
  cirrhosis or other liver diseases, including
  malignancy, hepatic resection, and biliary
  obstruction.
• Intrarenal vasoconstriction and avid sodium
  retention are early sequelae.

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HRS

• Patients with advanced liver disease, portal
  hypertension, and ascites also have increased
  plasma volume but reduced effective arterial
  blood volume as a consequence of systemic
  vasodilatation and pooling of blood in the portal
  circulation.
• Renal failure typically develops slowly over
  weeks or months in parallel with deteriorating
  hepatic function but may accelerate dramatically
  following a variety of hemodynamic insults,
  including hemorrhage, paracentesis, and
  overzealous use of diuretics, vasodilators, or
  cyclooxygenase inhibitors.

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HRS

• ARF progresses even after optimization of
  systemic hemodynamics and systemic arterial blood
  volume and removal of nephrotoxins, probably as a
  result of ongoing intrarenal vasoconstriction,
  hypoperfusion, and ischemia triggered by
  circulating factors or neural impulses
  originating in the failing liver.

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Diagnosis of HRS

• Chronic liver disease with acites
• Slow onset azotemia (plasma creatinine gt 1.5
  mg/dL)
• Tubular function good
• Urine to plasma osmolarity ratio gt 1.0
• Urine to plasma creatinine ratio gt 30
• Urine sodium concentration lt 10 mEq/dL
• No sustained benefit by expansion of
  intravascular space

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Differential Diagnosis
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Algorithm

• Risng serum creatinine, oliguria in patients
  with liver disease
• Step 1 History and Physical Examination ?
  Suspect HRS
• Step 2 Urinalysis
• Overly abnormal (cells, RBC, casts, protein)
  intrinsic renal disease
• Normal or minimally abnormal (granular or hyaline
  casts) ? Step 3

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Algorithm (2)

• Step 3 Urine and Serum Biochemistry
• Urine Na gt 40, UCRPCR lt 20, RFI gt 2 ATN
• Urine Na lt 20, UCRPCR gt 40, RFI lt 1? Step 4
• Step 4 Trial of volume expansion (1-2L saline)
• Urine output increases, Serum creatinine falls
  Reversible prerenal azotemia Fluid
• Oliguria persists, Creatinine stable or rising
  HRS Conservative renal failure treatment 10-20
  spontaneously reversible consider
  peritoneovenous shunt

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Management

• General measures
• Try not to make the diagnosis
• Attempt to rule out other likely diagnoses
• Acute renal failure
• Prerenal failure
• Use of CVP or Swan-Ganz catheter
• Volume chanllenge
• Primum non nocere

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Management

• Specific therapeutic considerations
• General
• Sodium and fluid restriction
• Correct acid-base disturbances
• Correct severe anemia
• Treat encephalopathy
• Ascites reinfusion
• Infusion of vasodilators
• Acetylcholine
• Phentolamine
• Prostaglandins A1 and E
• Dopamine

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Management

• Specific therapeutic considerations
• Portacaval shuntingl
• Dialysis
• Continuous arteriovenous ultrafiltration (CAVU)
• LeVeen (peritoneaovenous) shunt
• Hepatic transplantation

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Do Not Attempt to Make the Diagnosis of HRS
Firstly!!