Hepatorenal Syndrome Flashcards
Hepatorenal Syndrome
The management of hepatorenal syndrome (HRS) is notoriously difficult. The ideal treatment is liver transplantation but patients are often too unwell to have surgery and there is a shortage of donors
The most accepted theory regarding the pathophysiology of HRS is that vasoactive mediators cause splanchnic vasodilation which in turn reduces the systemic vascular resistance. This results in ‘underfilling’ of the kidneys. This is sensed by the juxtaglomerular apparatus which then activates the renin-angiotensin-aldosterone system, causing renal vasoconstriction which is not enough to counterbalance the effects of the splanchnic vasodilation
Hepatorenal Syndrome - Types
Hepatorenal syndrome has been categorized into two types:
Type 1 HRS
Rapidly progressive
Doubling of serum creatinine to > 221 µmol/L or a halving of the creatinine clearance to less than 20 ml/min over a period of less than 2 weeks
Very poor prognosis
Type 2 HRS
Slowly progressive
Prognosis poor, but patients may live for longer
Hepatorenal Syndrome - Mx
Management options
vasopressin analogues, for example terlipressin, have a growing evidence base supporting their use. They work by causing vasoconstriction of the splanchnic circulation
volume expansion with 20% albumin (HAS)
transjugular intrahepatic portosystemic shunt
Hepatorenal Syndrome Mx - Example Question
A 59-year-old male with known liver cirrhosis presents to the acute medical unit with a raised creatinine from baseline of 100µmol/L to 180µmol/L. He denies any reduced oral fluid intake. On examination, he is well perfused. There are no signs of dehydration. His abdomen is distended and shifting dullness is positive.
CRP 10mg/L
Hepatorenal syndrome is suspected. Which of the following is the first line treatment?
Bolus of normal saline fluid Bolus of Hartmann's solution Terlipressin > Terlipressin with albumin infusion Intravenous antibiotics
There are two types of hepatorenal syndrome. Type one is more aggressive with a worse prognosis. Regardless which type of hepatorenal syndrome, initial treatment is the same, which is intravenous terlipressin with albumin infusion. Simply giving fluid is not going to solve the problem because of the splanchnic vasodilation. There are no signs to suggest the acute kidney injury is secondary to sepsis which would require intravenous antibiotics.
Hepatorenal Syndrome - Example Question
A 50-year-old man with known alcoholic hepatitis is admitted to the Emergency Department generally unwell. He has had vague abdominal pain and general malaise for 4 days. His wife tells you he has been eating and drinking much less in that time and confirms he has been abstinent from alcohol for over a year.
On examination he appears clinically dehydrated and is drowsy. His heart rate is 121 beats per minute and his blood pressure is 102/55 mmHg. His temperature is 37.4 ºC. His chest is clear. His abdomen is soft with suprapubic tenderness but no organomegaly. There is some dullness in the flanks.
His urine dip is positive for nitrites and 1+ leucocytes.
His blood tests are as follows:
Hb 115 g/l Na+ 125 mmol/l Bilirubin 24 µmol/l Platelets 189 * 109/l K+ 4.9 mmol/l ALP 250 u/l WBC 14 * 109/l Urea 11 mmol/l ALT 124 u/l Neuts 10 * 109/l Creatinine 230 µmol/l γGT 255 u/l Lymphs 2.5 * 109/l CRP 75 mg/dl Albumin 30 g/l
He is treated with antibiotics and normal saline but after 24 hours his sodium is 124 mmol/l and creatinine is 229 µmol/l.
His urine sodium is 12 mmol/l and an ultrasound of the abdomen shows mild ascites, a cirrhotic liver and a normal renal tract.
What is the next most appropriate step?
5% dextrose Fluid restriction Hartmann's solution > Human albumin solution Hypertonic saline
This gentleman has hepatorenal syndrome secondary to his alcoholic liver disease. This is evidenced by his renal failure with hyponatraemia, low urine sodium and poor response to rehydration with normal saline.
Current guidelines recommend the next most appropriate step is rehydration with human albumin solution.
Reference: Nadim et al. Hepatorenal syndrome: the 8th international consensus conference of the Acute Dialysis Quality Initiative (ADQI) Group. Critical Care. 2012:16(1);R23
