#HEPATORENAL SYNDROME

Definition:

- increase in serum creatinine of = 0.3 mg / dl or increase of = 150 to 200 % (1.5- to 2-fold) from baseline or Cr >1.5 in patient with cirrhosis and ascites, absence of improvement after stop diuretics and 2 days of albumin at 1g/kg/day, with no other cause of AKI found (no shock, no nephrotoxic meds, no proteinuria >500mg/d, no microhematuria (>50RBC/HPF), no abnormal renal US)

- usually occurs in patients with refractory ascites with or without hyponatremia

- HRS-1 is a rapidly progressive type of acute renal failure and usually occurs in hospitalized patients <2 weeks after precipitating event, prognosis of type 1 HRS is very poor, with a median survival of ~ 2 weeks

- HRS-2 is a slower type of renal failure and mostly occurs in outpatients with refractory ascites, relatively longer median survival of ~ 6 months

Plan:

-discontinue diuretics

- expand the intravascular volume with i.v. albumin at a dose of 1 g/kg of body weight up to a maximum of 100 g or with saline solution in cases in which fluid loss from overdiuresis is suspected

- r/o infection, fluid, or blood loss - diagnostic paracentesis

- r/o post renal failure with renal ultrasound

- r/o intrinsic renal failure with urine studies (UA, UNa, UCr)

- first and only choice for definitive therapy for HRS is liver transplantation

- can bridge to liver transplant using combination of midodrine plus octreotide associated with i.v. albumin for at least 7 days

- Doses of octreotide and midodrine are titrated to obtain an increase in the mean arterial pressure of at least 15 mm Hg

- Midodrine is administered orally at an initial dose of 5 – 7.5 mg thrice daily and, if necessary, increased to 12.5 – 15 mg thrice daily.

- Octreotide is administered subcutaneously at an initial dose of 100 µg thrice daily and, if necessary, increased to 200 µg thrice daily

- IV albumin 50 - 100g IV qd

- liver transplant