Hepatorenal syndrome (HRS) - Quick revision

Table of Contents

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

Splanchnic vasodilation
Activation of sympathetic nervous system and renal-angiotensin-aldosterone-system (RAAS)
Cirrhotic cardiomyopathy
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