Hepatorenal Syndrome

Hepatorenal syndrome

Q. 1 Albumin treatment along with antibiotic in the setting of SBP(spontaneous bacterial peritonitisis indicated to prevent the development of hepatorenal syndrome is in all , EXCEPT:

 A

Serum creatine is > 1 mg/dl

 B

BUN > 30mg/dl

 C

Total bilirubin is > 4 mg/dl

 D

INR > 2

Q. 1

Albumin treatment along with antibiotic in the setting of SBP(spontaneous bacterial peritonitisis indicated to prevent the development of hepatorenal syndrome is in all , EXCEPT:

 A

Serum creatine is > 1 mg/dl

 B

BUN > 30mg/dl

 C

Total bilirubin is > 4 mg/dl

 D

INR > 2

Ans. D

Explanation:

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

1.Serum creatine is  > 1 mg/dl
2. BUN >   30 mg/dl
3. Total bilirubin is > 4 mg/dl
 
Dose o f albumin: 1. g/Kg within 6 hours of antibiotic treatment and 1 g/kg  on day 3.
A decrease in mortality from 30%to 10 % is noted.
Ref: AASLD practice  guidelines:Hepatology, Vol.49 ,No.6 ,2009.

Q. 2 Features of Hepatorenal syndrome are

 A

Urine sodium < 10 meq/1

 B

Normal renal histology

 C

Renal function abnormal even after liver become normal

 D

a and b

Q. 2

Features of Hepatorenal syndrome are

 A

Urine sodium < 10 meq/1

 B

Normal renal histology

 C

Renal function abnormal even after liver become normal

 D

a and b

Ans. D

Explanation:

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.

Diagnostic of Hepatorenal Syndrome

Major 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.


Q. 3 Which of the following statements is incorrect with regard to Hepatorenal syndrome in a patient with cirrhosis

 A

Createnine clearance < 40 ml/min

 B

Urinary sodium < 10mq/L

 C

Urine osmolality lower than plasma osmolality

 D

No sustained improvement in renal function after volume expansion.

Q. 3

Which of the following statements is incorrect with regard to Hepatorenal syndrome in a patient with cirrhosis

 A

Createnine clearance < 40 ml/min

 B

Urinary sodium < 10mq/L

 C

Urine osmolality lower than plasma osmolality

 D

No sustained improvement in renal function after volume expansion.

Ans. C

Explanation:

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.

Quiz In Between


Q. 4

Hepatorenal syndrome is characterized by all of the following except:     
March 2005

 A

Reduction in creatinine clearance

 B

Managed effectively by renal vasodilating agents.

 C

Proteinuria less than 500 mg/ d

 D

Normal intrinsic kidney

Q. 4

Hepatorenal syndrome is characterized by all of the following except:     
March 2005

 A

Reduction in creatinine clearance

 B

Managed effectively by renal vasodilating agents.

 C

Proteinuria less than 500 mg/ d

 D

Normal intrinsic kidney

Ans. B

Explanation:

Ans. B: Managed effectively by renal vasodilating agents.

HRS is defined as worsening azotemia with avid sodium retention and oliguria in the absence of identifiable specific cause of renal dysfucntion in setting of acute or advanced chronic liver disease

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.


Q. 5 All are true about hepatorenal syndrome except:

 A

Creatinine level raised

 B

Albumin infusion given

 C

Liver transplantation improves renal functions

 D

May occur in cirrhosis

Q. 5

All are true about hepatorenal syndrome except:

 A

Creatinine level raised

 B

Albumin infusion given

 C

Liver transplantation improves renal functions

 D

May occur in cirrhosis

Ans. E

Explanation:

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.

Quiz In Between



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