Hepatorenal Syndrome
OVERVIEW
- Hepatorenal Syndrome = 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. acute deterioration (doubling of creatinine or halving of CrCl over 2 weeks) 2. absent renal parenchymal disease 3. absent proteinuria 4. no shock 5. 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
INVESTIGATIONS
- concentrated urine with low Na+ (<10mol/L)
- few granular casts (doesn’t improve with fluid replacement)
- no proteinuria
- normal kidneys on U/S
DIAGNOSTIC 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
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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