Hepatorenal Syndrome
14/8/10
PY Mindmaps
E-medicine
SP Notes
= profound oliguria and Na+ retention in the setting of severe liver dysfunction (cirrhosis or
fulminant liver failure)
- usually fatal unless liver transplant performed.
- RRT can prevent advancement of condition
Pathophysiology
-?
- local production of intrarenal vasoconstrictors -> intrarenal vasoconstriction despite systemic
vasodilation
- increased Q with reduced SVR and MAP
- hypovolaemia and raised intra-abdominal pressure may also be factors
Types
I – rapidly progressive
1.
2.
3.
4.
5.
acute deterioration (doubling of creatinine or halving of CrCl over 2 weeks)
absent renal parenchymal disease
absent proteinuria
no shock
no history of nephrotoxic drugs
II – slower onset and progression
- renal failure in the context of end-stage liver disease that does not meet the criteria of type I
Risk Factors
- Na+ and H2O retention (urinary Na+ < 5mEq/L and dilutional hyponatraemia)
- low MAP
- poor nutrition
- reduced GFR
- high plasma renin activity
- oesophageal varices
- associated with infection, acute alcohol hepatitis, large volume paracentesis without albumin
replacement
Jeremy Fernando (2011)
Investigations
-
concentrated urine with low Na+ (<10mol/L)
few granular casts (doesn’t improve with fluid replacement)
no proteinuria
normal kidneys on U/S
DIAGNOTIC CRITERIA
- no other cause for renal failure
- Na+ and H2O retention
Major
-
chronic or acute liver disease with advanced hepatic failure + portal hypertension
low GFR (Cr > 130mmol/L or CrCl < 40ml/min)
absence of shock, bacterial infection and recent treatment with nephrotoxic agents
no sustained improvement in renal function post 1.5 of isotonic saline
proteinuria < 0.5g/day
no renal tract disease on U/S
Additional
-
urine volume < 500mL/day
urine Na+ < 10mmol/L
urine osmolality > plasma osmolality
urine red blood count < 50 per high power field
serum Na+ < 130mmol/L
Management
- diagnostic paracentesis (exclude SBP)
- albumin
- RRT
- transjugular intrahepatic portosystemic shunt (TIPS) – reduces blood pressure in portal vein
- liver dialysis (dialysis circuit with an albumin bound membrane to bind and remove toxins
normally cleared by the liver)
- IV clonidine (improves GFR)
- terlipressin/octreotide – decrease portal vein pressure
- liver transplant
Jeremy Fernando (2011)