Hepatorenal syndrome

Diagnostic Criteria

• Cirrhosis with ascites
• Serum creatinine >133 μmol/l (1.5 mg/dl)
• No improvement of serum creatinine (decrease to a level of ⩽133 μmol/l) after at least 2 days with diuretic withdrawal and volume expansion with albumin. The recommended dose of albumin is 1 g/kg of body weight per day up to a maximum of 100 g/day.
• Absence of shock
• No current or recent treatment with nephrotoxic drugs
• Absence of parenchymal kidney disease as indicated by proteinuria >500 mg/day, microhaematuria (>50 red blood cells per high power field) and/or abnormal renal ultrasonography

Classifications

• Type 1
  • Acute onset within 2 weeks of a precipitating factor for decompensated liver disease
  • Usual triggers are severe alcoholic hepatitis and spontaneous bacterial peritonitis
• Type 2
  • Slowly-progressive renal failure in the context of refractory ascites
  • Often with sodium retention
  • Can progress into type 1 HRS

Management

Type 1

• Rule out other causes
• Stop diuretics unless needed for management of volume status
• Albumin 1 g/kg body weight for 2 days followed by 20-40 g/day until 14 days or complete respond
  • +/- octreotide 100 mcg SC three times daily and midodrine 7.5 mg p.o. three times daily
  • Terlipressin (a vasopressin analogue) is probably better than octreotide and midodrine but not widely available
• Norepinephrine if in ICU
• Transplantation can be curative

Further Reading

• EASL Guidelines 2010