2+ Hepatorenal Syndrome

Question 1

What is hepatorenal syndrome?

Answer 1

A type of AKI that occurs in patients with acute or chronic liver disease. Occurs in the absence of hypovolaemia or significant abnormalities in kidney histology

Question 2

How is HRS classified?

Answer 2

Type 1:
Rapidly progressive AKI that is often bacterial triggered and associated with impaired cardiac and liver function

Type 2:
Moderate renal failure that fluctuates over time, associated with refractory ascites

Question 3

What is the aetiology of HRS?

Answer 3

Develops spontaneously in patients with cirrhosis
Can occur in patients with chronic liver disease, liver failure and portal HTN

Question 4

What is the pathophysiology of HRS?

Answer 4

The exact cause is unknown but blood vessel changes happen:

• Renal vasoconstriction = characteristic. Reduced blood flow/perfusion to the kidneys and impaired kidney function. Likely due to portal HTN, activation of vasoconstrictors and the suppression of vasodilators
• Cirrhotic cardiomyopathy may contribute to the development of HRS by decreased CO and abnormal widening of certain arteries with constriction of others

Triggers have been identified:
- Spontaneous bacterial peritonitis (SBP)
- Any infection
- GI bleeding
- Low BP

Question 5

What is the clinical presentation of HRS?

Answer 5

• Advanced cirrhosis
• Jaundice
• Ascites
• Peripheral oedema (kidneys are failing)
• Hepatosplenomegaly
• Oliguria (failing kidneys)
• Increased creatinine in the urine (kidneys are failing)

Question 6

What is the goal of HRS management?

Answer 6

To get the patient hemodynamically stable until the underlying hepatic cause can be fixed either by being overcome or a transplant. It is very rare for the renal complications to improve without the hepatic improving

Question 7

What is the management of HRS?

Answer 7

If you suspect HRS: do a albumin or saline fluid bolus. If it doesn’t improve then HRS. If cultures are negative then HRS.

Once you suspect HRS: give antibiotics until you know the cause/trigger/the cultures

1. Vasopressor + albumin (terlipressin)
2. Supportive therapy: fluid status, urine output and UECs monitored
3. Prevent hyponatremia
4. Ascites: paracentesis
5. TIPS
6. Dialysis if needed
7. Liver transplant

Question 8

How can you potentially prevent HRS?

Answer 8

Alcohol related: prednisolone

SBP related: ceftriaxone + albumin

Question 9

What are the complications of HRS?

Answer 9

Type 1: more likely to develop HE

Type 2: develop refractory ascites