Name
HEPATORENAL SYNDROME
DESCRIPTION
DETAIL
CAUSES: * End stage liver disease from alcohol or toxins, viral hepatitis, fulminant hepatic failure, malignancy or any other injury which leads to cirrhosis (e.g., Schistosoma) with accompanying risk factors -------------------------------------------------------------------------- DIFFERENTIAL DIAGNOSIS: . For abrupt onset of oliguria in cirrhosis . Volume contraction . Cardiac failure (possibly alcoholic cardiomyopathy) . Acute vasomotor nephropathy . Obstruction . Interstitial nephritis (drug-induced). Azotemia in the setting of cirrhosis with appropriate spot urine values (consistent with tubular function): . Na+ < 10 mEq/L (10 mmol/L) . Fractional excretion of sodium < 1% . Urine/plasma creatinine > 30:1 . Osmolality mild to moderate reduction in concentrating ability (400-600 mOsm/kg/water) . All reversible causes should be ruled out (e.g., prerenal; obstruction). . Urinalysis - absence of ATN casts; < 500 mg/dL protein . Lack of improvement in renal function following diuretic withdrawal and expansion of plasma volume with 1.5 L of normal saline . Minor criteria: urine volume < 500 cc/day; urine red cells < 50 hpf; serum sodium < 130 mcg/L . Other: prolonged prothrombin time, decreased serum albumin concentration, elevated bilirubin SPECIAL TESTS Xenon 133 washout curves show a profound reduction in renal cortical perfusion (historic interest) IMAGING Renal ultrasound shows normal kidneys without obstruction DIAGNOSTIC PROCEDURES Though experimental presently, renal duplex Doppler ultrasonography appears to have predictive value in separating cirrhotics who will develop HRS from those who wonβt based on resistive index
TYPENOTES
RISK FACTORS: Any reduction of effective blood volume in cirrhosis including: Excessive diuresis and gastrointestinal blood loss(e.g.,variceal bleeding), Excessive diarrhea (lactulose-induced), Bacteremia,Reduction in venous return with tense ascitesAPPROPRIATE HEALTH CARE Maintenance of volume status in cirrhosis GENERAL MEASURES . Supportive . Avoid iatrogenic events that precipitate HRS . Diagnose and treat correctable causes of azotemia in cirrhosis: volume expanders (100 gm albumin in 500 cc normal saline) should always be tried if possible, left ventricular function maximized if possible, relief of urinary obstruction when present . Other . Large volume paracentesis . Dialysis is only indicated as ancillary support for patients awaiting liver transplant or in patients with acute potentially reversible liver failure . Head-out water immersion and LaVeen shunts of dubious value . Acute liver failure with HRS may reverse if the liver regenerates SURGICAL MEASURES Liver transplantation when feasible is the only curative treatment. The observed 3 months to estimated 6 months to 1year survival in patients with transjugular intrahepatic portosystemic stent-shunts is improved. LeVeen shunt may provide similar benefit. ACTIVITY Bedrest PATIENT EDUCATION In alcoholic cirrhosis, abstention from alcohol is essential and may prevent further deterioration of cirrhosis DRUG(S) OF CHOICE Low dose dopamine may provide temporary benefi t. Not curative. ALTERNATIVE DRUGS Vasopressin analogues (terlipressin and ornipressin) combined with plasma volume expansion demonstrate some effect on the short-term reversibility of renal dysfunction. May act as a bridge to liver transplant. Questions of efficacy persist, however. EXPECTED COURSE/PROGNOSIS β’ Grave without liver transplant in chronic cirrhosis or without regeneration of the liver in acute fulminant failure β’ If a liver transplant is performed, actuarial patient survival after transplant is less in patients with preceding hepatorenal syndrome β’ The patient may be supported with hemodialysis, continuous arteriovenous hemofiltration (CAVH) or continuous arteriovenous hemodialysis (CAVHD) and transjugular portosystemic stent-shunt prior to organ availability for transplant
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
BLOOD UREA, SERUM CREATININE, URINE ROUTINE, ULTRA SOUND K.U.B., RENAL DMSA SCAN, COMPLETE BLOOD COUNT, LIVER FUNCTION TEST