Hepatorenal Syndrome



Hepatorenal Syndrome





(Am J Gastroenterol. 2005;100:460-67)


DEFINITION:



  • Renal failure (progressive azotemia) in patients with cirrhosis, liver failure, and portal hypertension


EPIDEMIOLOGY:



  • 10% of hospitalized patients with cirrhosis and ascites


  • 20% at 1 year, 40% at 5 years in patients with cirrhosis and ascites


ETIOLOGIES:



  • Precipitants: GI Bleed, Overdiuresis, Paracentesis, Nephrotoxic drugs: aminoglycosides/NSAIDs


  • Type 1 (see below) may be associated with SBP, Acute alcohol hepatitis, LVP without albumin expansion, GI bleed


PATHOPHYSIOLOGY:



  • Hallmark is severe vasoconstriction of the renal circulation


  • MOA progression and [Treatment interventions at each stage]:



    • Cirrhosis [OLT] » Portal HTN » Splanchnic arterial vasodilation (mainly nitric oxide) [Midodrine/Terlipressin] » Arterial underfilling (↓ effective volume) [Albumin] » Stimulation systemic vasoconstrictors (Renin-angiotensinogen-aldosterone RAAS, Sympathetic nervous system SNS, Endothelin) [TIPS] » Renal vasoconstriction [Avoid NSAIDs] »



      • Early stages of Cirrhosis » ↑ systemic and local vasodilators with preserved renal perfusion


      • Late stages of Cirrhosis » ↓ in local vasodilators (overwhelmed) with increased local vasoconstrictors » HRS

    In other words, a vicious cycle ensues: hypoperfusion leads to more imbalance in intrarenal vasoactive systems, i.e. vasoconstrictors


CLINICAL MANIFESTATIONS/PHYSICAL EXAM:



  • No specific clinical findings, most have features of advanced liver disease such as refractory ascites


  • Low arterial blood pressure, reduced systemic vascular resistance, tachycardia, and increased cardiac output

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Aug 24, 2016 | Posted by in GASTROENTEROLOGY | Comments Off on Hepatorenal Syndrome

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