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.

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: 1Handbook of Liver Disease By Lawrence S. Friedman, Emmet B. Keeffe

• 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