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Hepato-renal syndrome

Introduction

Renal failure in advanced liver disease, in the absence of other causes of renal failure.

NB. renal failure in patients with cirrhotis is far more likely to be due to infection, glomerulonephritis, dehydration, etc.

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Precipitating factors

- bacterial infection (esp. SBP - spontaneous bacterial peritonitis)
- large-volume paracentesis (>5 L) without plasma expansion (therefore give (IV) albumin)
- GI bleeding

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Classification

	TYPE 1	TYPE 2
DEFINITION	100 % ­ [Cr] in 2 weeks (to > 211 microM)	slower rate of progression
CLINICAL PICTURE	severe renal failure	refractory ascites
TYPICAL GFR	< 20 ml/min	> 20 ml/min
TYPICAL [Cr]	approx. 350 microM	approx. 180 microM
MEDIAN SURVIVAL	2 weeks (hospital mortality > 90 %)	6 months
SURVIVAL WITH TIPS	2 – 4 months
MANAGEMENT	inpatient	outpatient

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Management: general

Renal failure
- [creatinine] > 133 mM equivalent to GFR of ~ 30 ml / min
- exclude other causes (pre-renal, drugs, ATN, infection, etc.)
- HRS unlikely if: no hyponatraemia (dilutional, i.e. despite Na⁺ retention), no ascites

Prevention of HRS
Identify at-risk patients
- cirrhotics with ascites
- renal Na⁺ retention
- diluational hyponatraemia

Prophylaxis in SBP (spontaneous bacterial peritonitis)
- Antibiotics
- albumin (decreases mortality around 66 %)

Prophylaxis in alcoholic hepatitis
- pentoxifylline (decreases mortality around 50 %)

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Management: type 1

Medical
- admit
- fluid restrict (< 1000 mL / day)
- vasoconstrictors + (IV) albumin, e.g. vasopressin analogues / alpha- agonists *
- early treatment of complications (esp. infections)

Interventional
- TIPS ** (SEs = hepatic encephalopathy)

Surgical
- liver transplantation

* SEs = peripheral, splanchnic, cardiac ischaemia
** transjugular intrahepatic portosystemic shunt

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Management: type 2

Medical
- manage possible as outpatient
- Na⁺ restriction (< 80 mmoles / day)
- fluid restriction (if hyponatraemia present)
- diuretics (avoid K⁺-sparing)
- repeated paracentesis (with (IV) albumin)

Surgical
- liver Tx

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