Hepatorenal syndrome (HRS) – Quick revision

New Criteria for HRS

1. Cirrhosis with ascites

2. Serum creatinine >1.5mg/dl

3. No sustained improvement in renal function after 2 days of diuretic withdrawl (if on diuretics) and volume expansion with albumin infusion at 1 gm/kg/day upto a maximum of 100 gm/day.

4. No evidence of shock

5. No nephrotoxic drugs

6. No evidence of parenchymal kidney disease

  • Proteinuria <0.5 gm/day
  • No microhematuria (RBC <50/hpf)
  • Normal renal ultrasonography

Types of HRS

Type 1 HRS

  • Rapid and progressive impairment in renal function (increase in serum creatinine of ≥100% compared to baseline to a level higher than 2.5mg/dl in <2 weeks)

Type 2 HRS

  • Stable or less progressive impairment in renal function
  • Type 2 HRS may convert to Type 1 HRS spontaenously or following precipitating event such as SBP.
HRS pathophysiology
Pathophysiology of HRS from Scientific research open access

Pathophysiology of HRS

  1. Splanchnic vasodilation
  2. Activation of sympathetic nervous system and renal-angiotensin-aldosterone-system (RAAS)
  3. Cirrhotic cardiomyopathy
  4. Increased vasoactive mediators – LTs, TXA2, endothelins, etc.

Spontaenous bacterial peritonitis (SBP) is the most important risk factor for HRS. 30% patients with SBP may go in HRS.

Prevention of SBP

1. Diuretics: concentrates ascitic fluid raising the opsonic activity of asicitic fluid.

2. Infection treatment: early recognition and treatment of localized infection like cystitis and cellulitis.

3. Restrict proton pump inhibitor: PPI facilitate enteric colonization, overgrowth and translocation into peritoneum.

4. Antibiotic prophylaxis: 1

  • Indications:
    1. Cirrhosis with gastrointestinal bleeding
    2. One or more episode of SBP
    3. Ascitic fluid protein <1 gm/dl during hospitalization (US recommendation)
    4. Cirrhosis and ascitic fluid protein <1.5 gm/dl with impaired renal function (creatinine ≥1.2 mg/dl, BUN ≥25 mg/dl or Na+ ≤130 mEq/l) or liver failure (Child pugh score ≥9 and bilirubin ≥3 mg/dl)
  • Choice of antibiotics for prophylaxis:
    • Trimethoprim-sulfamethoxazole (one double strength tabled once daily) OR
    • Ciprofloxacin 500 mg/day OR
    • Norfloxacin 400 mg/day
  • Duration of prophylaxis:
    • For 7 days in patients with cirrhosis and GI bleeding
    • Until hospitalization for patients with ascitic fluid protein <1 gm/dl during hospitalization
    • For other conditions – continue until ascites disappears or decompensated liver disease improves

Management of HRS

  • Terlipressin (vasoconstrictor): 1-2 mg IV every 4-6 hours
  • Albumin: 1 gm/kg (to 100 mg) on day 1 then 20-40 mg daily
  • TIPPS: if response is suboptimal
  • Liver transplant: Optimal

Reference: EASL Clinical Practice Guidelines

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