Hepatorenal Syndrome
Basics
Description
Description
- Renal failure (RF) in patients with acute or chronic liver disease with no other identifiable cause of renal pathology
- Hepatorenal syndrome (HRS) represents significant decline in renal perfusion due to severe liver disease:
- Type I HRS:
- Acute form with spontaneous RF in patients with liver disease
- Rapidly progressive
- 90% mortality within 3 mo
- Seen with acute liver failure or alcoholic hepatitis
- Oliguric or anuric at presentation
- Type II HRS:
- Slow course of RF
- Seen in patients with diuretic resistant ascites
- Lower mortality than type I HRS
- Type I HRS:
- Hallmarks of HRS:
- Patients must have cirrhosis and ascites
- Prerenal disease
- A functional form of acute kidney injury (AKI) due to renal vasoconstriction
- AKI according to International Club of Ascites (ICA) criteria
- Reversible renal vasoconstriction and mild systemic hypotension, but without shock
- Kidneys have normal histology and structure on US
- Lack of improvement in renal function after volume expansion with albumin and diuretic withdrawal for 48 hr
- No current use of nephrotoxic drugs
- Liver disease causes systemic vasodilation with decrease in arterial blood volume:
- Reflex activation of sympathetic nervous system
- Activation of renin–angiotensin–aldosterone system (RAAS)
- Stimulation of numerous vasoactive substances:
- Nitric oxide
- Prostacyclin
- Atrial natriuretic peptide (ANP)
- Arachidonic acid metabolites
- Platelet-activating factor
- Endothelins
- Catecholamines
- Angiotensin II
- Thromboxane
- Action of vasoconstrictors prevails over vasodilator effects:
- Renal hypoperfusion ensues due to renal cortical vasoconstriction
- Decrease in renal blood flow and glomerular filtration rates (GFRs)
- Decreased urine sodium excretion (U Na <10 mEq/d)
- Incidence of HRS:
- 18% at first year, 39% at 5 yr
- Hyponatremia and high plasma renin levels are risk factors
Etiology
Etiology
- Chronic liver disease, especially alcohol related (cirrhosis, severe alcoholic hepatitis)
- Fulminate hepatic failure
- Precipitating factors:
- Decreased effective blood volume:
- GI bleeding
- Vigorous diuresis
- Large-volume paracentesis
- Use of nephrotoxic agent:
- NSAIDs
- Aminoglycoside
- Sepsis:
- Spontaneous bacterial peritonitis (SBP) leads to a 33% chance of developing RF during that year
- SBP prophylaxis reduces the chance of developing acute RF
- Decreased effective blood volume:
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Citation
Schaider, Jeffrey J., et al., editors. "Hepatorenal Syndrome." 5-Minute Emergency Consult, 6th ed., Lippincott Williams & Wilkins, 2020. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307452/2.2/Hepatorenal_Syndrome.
Hepatorenal Syndrome. In: Schaider JJJ, Barkin RMR, Hayden SRS, et al, eds. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307452/2.2/Hepatorenal_Syndrome. Accessed October 15, 2024.
Hepatorenal Syndrome. (2020). In Schaider, J. J., Barkin, R. M., Hayden, S. R., Wolfe, R. E., Barkin, A. Z., Shayne, P., & Rosen, P. (Eds.), 5-Minute Emergency Consult (6th ed.). Lippincott Williams & Wilkins. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307452/2.2/Hepatorenal_Syndrome
Hepatorenal Syndrome [Internet]. In: Schaider JJJ, Barkin RMR, Hayden SRS, Wolfe RER, Barkin AZA, Shayne PP, Rosen PP, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. [cited 2024 October 15]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307452/2.2/Hepatorenal_Syndrome.
* Article titles in AMA citation format should be in sentence-case
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T1 - Hepatorenal Syndrome
ID - 307452
ED - Barkin,Adam Z,
ED - Shayne,Philip,
ED - Rosen,Peter,
ED - Schaider,Jeffrey J,
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ED - Hayden,Stephen R,
ED - Wolfe,Richard E,
BT - 5-Minute Emergency Consult
UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307452/2.2/Hepatorenal_Syndrome
PB - Lippincott Williams & Wilkins
ET - 6
DB - Emergency Central
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