Hepatorenal syndrome (HRS) is a manifestation of extreme circulatory dysfunction. It develops in the setting of an advance stage in cirrhosis. HRS is diagnosed clinically. Its definition has been updated recently in accordance with the acute kidney injury (AKI) criteria. The current standard of care involves the use of vasoconstrictor therapy (i.e., terlipressin) and volume expansion with albumin.
Treatment is effective in only 40%-50% of cases and it recurs in up to 50% of those cases responding to treatment. Liver transplant (LT) should be considered in all patients without contraindications for it.
Diagnosis |
Cirrhosis with Ascites
· Increase in serum creatinine = >0.3mg/dl within 48hrs ,
>50% from baseline in the last 7days
· Absence of shock
· No response despite Diuretic withdrawal for 2 days and Volume expansion with Albumin 1gm/kg/day (max.100mg/day)
· No nephrotoxic drugs current or recent
· No parenchymal kidney disease defined as proteinuria <500mg/day, hematuria <50RBC/HPF, Normal USG
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Investigations
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Hemogram RFT,LFT,INR, Sugar, ECG
· Urine routine microscopy , spot sodium, Culture
· Urine 24 hrs Sodium and protein
· USG for liver , kidney and urinary tract
· Ascitic fluid analysis : TLC , DLC , SAAG, Culture
· Chest X ray
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Staging of AKI : Based on increase in Serum Cr
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· Stage 1: >0.3MG/DL OR 1.5 TO 2 fold from base line
· Stage 2 >2-3 fold from baseline
· Stage 3 >3 fold from base line OR Serum Cr >4mg/dl+ acute increase of >0.3md/dl
or Need for renal replacement therapy.
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Management
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Stop Diuretics and rule out renal, prerenal and postrenal causes. Rule out infections
Rule out SBP so have a diagnostic ascitic tap and send in a blood culture bottle for culture studies
· Monitor input and output, CVP, MAP, Urinary sodium
· Screen for sepsis: Blood culture, Urine C/S,
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IV Albumin 1gm/Kg for 2 days followed by 20-60 gm/day maintaining CVP of 10-15cm of water
· Vasoconstrictor therapy :
A) First-line therapy: IV Terlipressin 1mg 4-6 hrly
Response:
Decrease in serum creatinine by at least 25% from baseline on day 3 of therapy ….. Continue treatment till serum creatinine has decreased below 1.5mg/dl
IF No response after 72hrs
Then Increase Terlipressin 2mg 4-6hrly
B)Second-line regime
IV Noradrenaline : infusion 0.5mg/h to increase in MAP by at least 10mmHg
urine output >200ml/4h,if not ,dose increased every 4h in steps of 0.5mg/h up to the maximum of 3mg/h
ORAL Midodrine 2.5-7.5mg/8h , increase to 12.5mg/8hr
B) TIPS
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