Table Of Contents
Hepatorenal Syndrome (HRS)
Hepatorenal syndrome is renal impairement caused by changes in renal blood flow which is related to cirrhosis and portal hypertension. There is splanchnic and systemic vasodilation and renal vasocontriction caused by bacterial translocation, cytokine release, mesenteric angiogenesis and altered renal auto-regulation. HRS is a diagnosis of exclusion since other causes can cause renal dysfunction in patients with liver disease e.g. acute tubular necrosis
HRS carries a poor prognosis unless the patient requires liver transplant.
Classification of hepatorenal syndrome
| Classification | Description |
|---|---|
| HRS 1 | Rapidly progressive deterioration in circulatory and renal function often triggered by a deteriorating pathology. Accompanied by other systemic signs including hypotention. Has a median survival of < 2 weeks. May require hemodialysis. |
| HRS 2 | Steady deterioration of renal function. Usually has ascites resistant to diuretics since the kidneys are unable to excrete sodium. Median survival of ~ 6 months. May require transjugular intrahepatic portosystemic shunting (TIPS) |
- Signs and symptoms
- Oliguria
- Hypotension (HRS 1)
- Platypnoea
- Investigations
- UEC: note that urea and creatinine are often abnormally low in patients with liver disease which can make eGFR values appear more than they are
- Rise in creatinine > 220 umol/L less than 2 weeks (as long as creatinine is doubled from baseline) in HRS 1
- Creatinine > 133 umol/L in HRS 2
- Urinalysis + MCS
- Low urine sodium
- UEC: note that urea and creatinine are often abnormally low in patients with liver disease which can make eGFR values appear more than they are
- Treatment
- Teriplessin + albumin to resist hypervolaemia
- Midodrine + octreotide + albumin
- Noradrenaline in the ICU setting
- Dialysis
- Transjugular intreaheptic portosystemic shunt
- Liver transplant
