Hepatorenal Syndrome

Page Contents

1 WHAT IS IT?
2 WHY IS IT A PROBLEM?
3 WHAT MAKES US SUSPECT IT?
4 HOW DO WE CONFIRM A DIAGNOSIS?
5 HOW DO WE RULE OTHER DIAGNOSES OUT?
6 HOW DO WE TREAT IT?
7 HOW WELL DO THE PATIENTS DO?
8 WAS THERE A WAY TO PREVENT IT?
9 WHAT ELSE ARE WE WORRIED ABOUT?
10 OTHER HY FACTS?
11 FURTHER READING

WHAT IS IT?

Hepatorenal syndrome is a condition that is defined as rapidly developing renal failure that is secondary to cirrhosis. Most of the time this condition is caused by the management of a patient’s liver disease. A classic scenario is that patines with ascites are over treated with diuretics (leading to what is initially pre-renal kidney failure). It is also thought that systemic vasodilation (from portal hypertension) contributes to the poor perfusion of the kidney.

WHY IS IT A PROBLEM?

Kidney function is quite important, and patients who have hepatorenal syndrome are unable to clear waste materials from their blood.

WHAT MAKES US SUSPECT IT?

Risk factors: established liver disease (any causing portal hypertension/ascites), diuretic usage.

Presentation likely includes many of those seen in portal hypertension AND those seen with kidney failure which can include:

Decreased urine output
Nausea and vomiting
Change in mental status
Fatigue/weakness

HOW DO WE CONFIRM A DIAGNOSIS?

Major diagnostic criteria include the following:

Cirrhosis with ascites
Serum creatinine > 1.5 mg/dL
No improvement in serum creatinine after ≥ 2 days of diuretic withdrawal and plasma volume expansion with albumin
Absence of shock
No current/recent usage of nephrotoxic drugs
No evidence of parenchymal renal disease (proteinuria < 0.5 g/day, no microhematuria, and normal renal ultrasound)

*If the kidney failure is caused by any process involving a primary issue with the kidney, the condition can not be labeled hepatorenal syndrome

HOW DO WE RULE OTHER DIAGNOSES OUT?

Excluding other possible causes of kidney failure (such as nephrotoxic drugs, or intrinsic parenchymal issues with the kidney) help to narrow the differential for hepatorenal syndrome.

HOW DO WE TREAT IT?

Liver transplant is ultimately what is required for patines with hepatorenal syndrome.

HOW WELL DO THE PATIENTS DO?

Patients have a poor prognosis if they have been diagnosed with hepatorenal syndrome. Even with a liver transplant their life expectancy is drastically shortened with this condition.

WAS THERE A WAY TO PREVENT IT?

This condition can be difficult to prevent, however when managing patients with liver cirrhosis/portal hypertension great care should be taken when using diuretics.

WHAT ELSE ARE WE WORRIED ABOUT?

Spontaneous bacterial peritonitis (SBP) is a possible outcome if the peritoneal fluid from the patient’s ascites becomes colonized with bacteria.

Dilutional hyponatremia can occur in these patients and fluid restriction combined with vasopressin antagonists (such as spironolactone) can help manage this condition.