Hepatorenal Syndrome

Name: Hepatorenal Syndrome
Uploaded: 2016-05-02
Duration: 2 min 7 s
Description: The lecture Hepatorenal Syndrome by Carlo Raj, MD is from the course Liver Diseases: Basic Principles with Carlo Raj.

by Carlo Raj, MD

Hepatorenal Syndrome (Clinical)

Hepatorenal syndrome (HRS) is a “functional” type of acute kidney injury (AKI) in patients who have portal hypertension, usually due to cirrhosis. HRS may also be caused by other liver diseases which are associated with portal hypertension, which causes decreased systemic arterial blood volume and activation of neurohormonal mechanisms, including the renin-angiotensin-aldosterone system. The resulting vasoconstriction and reduced renal perfusion trigger the release of vasodilatory substances like nitric oxide, which induces splanchnic arterial vasodilatation, leading to a decrease in systemic vascular resistance and effective circulating volume, thereby exacerbating renal hypoperfusion. HRS is a diagnosis of exclusion, and is associated with a poor prognosis. Without treatment, most patients die within weeks of the onset of AKI. Patients typically present with a progressive rise in serum creatinine, a benign urine sediment, no (or minimal) proteinuria, and a low urine sodium concentration. Ascites is often present, and severe cases are associated with oliguria. Treatment is aimed at improving liver function, if possible. Medical therapy includes increasing the systemic blood pressure with norepinephrine and albumin infusions, and administering agents that cause splanchnic vasoconstriction (e.g., terlipressin). Transjugular intrahepatic portosystemic shunt (TIPS) may be successful, and dialysis is a temporizing solution while waiting for liver transplant. The prognosis of patients with HRS is highly dependent upon reversal of the hepatic failure, whether spontaneous, following medical therapy, or following transplantation.

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00:01 An important understanding of Hepatorenal Syndrome is required.

00:07 This is a functional renal failure without underlying renal pathology.

00:12 This is not nephralic syndrome, this is not nephrotic syndrome nor it is arteriosclerosis taking place at the renal artery.

00:19 The perfectly functional kidney, used to be the patient developed portal hypertension and now, there is a functional renal failure Is that clear? Very interesting. Important? Yes.

00:35 Hepatorenal syndrome-acute kidney injury (or HRS-AKI) is a serious condition defined as an acute rise in serum creatinine (typically of at least 2-fold).

00:46 This renal dysfunction does not respond to diuretic withdrawal or volume expansion with IV albumin administration.

00:52 HRS-non-AKI refers to renal dysfunction that is more insidious or otherwise does not meet criteria for AKI. It may also be defined by “diuretic-refractory ascites.

01:06 Diagnosis of exclusion.

01:07 Here, you'll find that urine sodium is less than 10mEq/L urine sodium is less than 10mEq/L It means to say, it is not able to properly take care of sodium handling.

01:16 Steps should be taken to improve liver function (where possible) so patients will be told to stop drinking, treating underlying HBV infections can also be helpful.

01:28 Treatment options include vasoconstrictors (such as terlipressin or norepinephrine) in combination with IV albumin. Octreotide plus midodrine is an alternative option.

01:39 Interventions may include dialysis or TIPS procedure.

01:42 Interestingly, in these patients, that do recieve the transplantation, renal function does seem to recover.

01:50 it seems as though the kidney actually comes back to life.

01:54 Fascinating. We don't know a whole lot about it but we know just enough, where that statistic of 100% mortality puts it on the radar, big time.

About the Lecture

The lecture Hepatorenal Syndrome by Carlo Raj, MD is from the course Liver Diseases: Basic Principles with Carlo Raj.

Included Quiz Questions

What is the treatment of choice for patients with hepatorenal syndrome?

Liver transplantation
Chemotherapy
Steroids
Antibiotics
Antihypertensives

Which of the following factors determines the type of hepatorenal syndrome?

Rapidity in the loss of renal function
Amount of loss of renal function
Severity of loss of renal function
Severity of loss of hepatic function
Rapidity of loss of hepatic function

Which of the following statements regarding hepatorenal syndrome is NOT true?

HRS-NAKI (type 2 HRS) shows rapid loss of renal function.
It includes HRS-AKI (type 1) and HRS-NAKI (type 2).
It is defined as functional renal failure without underlying renal pathology secondary to portal hypertension.
HRS-AKI (type 2 HRS) has a high mortality rate.
It is usually a diagnosis of exclusion, with urine Na < 10 mEq/L.

Which of the following statements regarding hepatorenal syndrome is TRUE?

HRS-AKI (type 1 HRS) is defined as at least a 2-fold increase in serum creatinine to a level > 2.5 mg/dL in less than 2 weeks.
HRS-NAKI (type 2 HRS) shows rapid loss of renal function.
It is treated with steroids and antihypertensives.
It is usually diagnosed with certainty based on the renal function only.
It does not improve after liver transplantation.

A patient is diagnosed with hepatorenal syndrome. Which of the following laboratory abnormalities would be expected in this patient?

Serum creatinine – increased Urine Na – decreased Serum transaminases – increased
Serum creatinine – normal Urine Na – decreased Serum transaminases – increased
Serum creatinine – increased Urine Na – decreased Serum transaminases – normal
Serum creatinine – increased Urine Na – increased Serum transaminases – increased
Serum creatinine – decreased Urine Na – decreased Serum transaminases – decreased

A 48-year-old man with cirrhosis is admitted to the hospital with spontaneous bacterial peritonitis. His lab values show: total bilirubin = 2.0 mg/dL, albumin level = 2.0 g/dL, creatinine = 1.2, and urine Na = 8 mEq/L on hospitalization. On day 6, the creatinine rises to 4.2, and the patient is anuric. What is the diagnosis of the patient?

Type 1 hepatorenal syndrome (HRS-AKI)
Type 2 hepatorenal syndrome (HRS-NAKI)
Hepatopulmonary syndrome
Non-alcoholic liver disease
Cirrhosis with portal hypertension

Author of lecture Hepatorenal Syndrome

Carlo Raj, MD

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