Hepatorenal syndrome

In patients with SBP along  with cefotaxime albumin infusion is indicated in the setting , when

Answer is A & B (urine Na < 10 meq/l and Normal Renal Histology)

Hepatorenal syndrome is associated with normal renal histology and supported by a urine sodium excretion l0meq/L

Hepatorenal syndrome

• Hepatorenal syndrome is defined as a state of functional renal failure (Reduced GFR) in patients with severe liver disease
• Structurally /Histologically the kidneys are normal and recover function after successful liver transplantation.
• The pathogenetic hallmark of hepatorenal syndrome is intense renal vasoconstriction with coexistent systemic vasodilatation
• The diagnosis of hepatorenal syndrome is considered in accordance with the following diagnostic criteria.

• Low glomerular filtration rate. as indicated by serum creatinine > 1.5 mg/dL or 24-hr creatinine clearance < 40 mL/min
• Absence of shock, ongoing bacterial infection, fluid losses, and current treatment with nephrotoxic drugs
• No sustained improvement in renal function (decrease in serum creatinine to 1.5 nig/dL or increase in creatinine clearance to 40 mL/min) after diuretic withdrawal and expansion of plasma volume with 1.5L of a plasma expander
• Proteinuria mg/d1, and no uhrasonographic evidence of obstructive uropathy or parenchymal renal disease Additional criteria
• Urine volume < 500 mL/d
• Urine sodium < 10 meq/L
• Urine osmolality greater than plasma osmolality
• Urine red blood cells <50/high- power_. field
• Serum sodium concentration < 130 niEqL

Note: All major criteria must be present for the diagnosis of hepatorenal syndrome.

Additional criteria are not necessary for the diagnosis but provide supportive evidence.

Answer is C (Urine osmolality is lower than plasma osmolality):

Hepatorenal syndrome is associated with urine osmolality greater than plasma osmolality (and not lower than plasma osmolality).

creatinine clearance < 40 ml/minute and poor response to volume expansion are major diagnostic features of hepatorenal syndrome while urinary sodium of less than 10 mmol/L is an additional criteria that provides supportive evidence.

Ans. B: Managed effectively by renal vasodilating agents.

No specific tests establish the diagnosis of HRS.

Diagnosis of HRS is based on the presence of a reduced GFR in the absence of other causes of renal failure in patients with chronic liver disease. The following criteria help to diagnose HRS:

Major criteria: All major criteria are required to diagnose HRS.

• Low GFR, indicated by a serum creatinine level higher than 1.5 mg/ dL or 24-hour creatinine clearance lower than 40 mL/ min
• Absence of shock, ongoing bacterial infection and fluid losses, and current treatment with nephrotoxic medications
• No sustained improvement in renal function (decrease in serum creatinine to40 mL/ min) after diuretic withdrawal and expansion of plasma volume with 1.5 L of plasma expander
• Proteinuria less than 500 mg/ d and no ultrasonographic evidence of obstructive uropathy or intrinsic parenchymal disease

Additional criteria: Additional criteria are not necessary for the diagnosis but provide supportive evidence.

• Urine volume less than 500 mL/d
• Urine sodium level less than 10 mEq/ L
• Urine osmolality greater than plasma osmolality
• Urine red blood cell count of less than 50 per high-power field
• Serum sodium concentration less than 130 mEq/ L

The best therapy for HRS is liver transplantation.

Answer- E. Low dose dopamine infusion is very effective

• The hepatorenal syndrome (HRS) is a form of functional renal failure without renal pathology that occurs in about 10% of patients with advanced cirrhosis or acute liver failure.
• There are marked disturbances in thc arterial renal circulation in Patients with HRS.
• TyPe I HRS- a significant reduction in creatinine clearance within 1-2 weeks of presentation.
• Type 2 HRS- an elevation of serum creatinine level.
• HRS is often seen in patients with refractory ascites.

Treatment-

• dopamine or prostaglandin analogues were used as renal vasodilating medications.
• Patients are treated with midodrine, an alpha-agonist, along with octreotide and intravenous albumin.
• The best theragy for HRS is liver transplantation.