Day #107 - Hepatorenal Syndrome

Today we talked about acute decompensated cirrhosis with massive ascites and hepatorenal syndrome.

Hepatorenal syndrome (20% or acute renal failure in cirrhotics) (good articles here and here):

• Two types:
  
  • Type 1: Acute rise in creatinine (usually within 2 weeks)
  • Type 2: More gradual rise and usually not progressive
    
• Criteria for diagnosis (revised 2007):
  
  • Cirrhosis with ascites
    
  • Creatinine >120
  • No current or recent nephrotoxins
  • No shock
  • Doesn't improve with volume rescucitation (with albumin) and stopping diuretics x 2 days
    
  • Less then 500mg proteinuria/24h and no large hematuria or sonographic evidence of renal parenchymal disease or obstruction
• Treatment of type 1 HRS
  
  • Generally as a bridge to transplantation! Not usually on their own if transplant will never be an option
    
  • Norepinephrine infusion, or midodrine 7.5-12.5mg PO TID with octreotide 100-200mcg SC TID, or terlipressin infusion
    
    • With albumin 1g/kg on day 1 and 20-40g q24h
  • Treat 5-15 days with goal Cr <120
  • Haemodialysis should generally *not* be used as it does not improve the poor outcomes -- though can be used as a bridge to transplant
  • TIPS - in patients with CPS less than twelve and bilirubin <85 and without severe encephalopathy can have survival benefit.
    
• Outcomes
  

Alcoholic hepatitis:

• People talk about treating with corticosteroids in severe disease; however, a recent meta-analysis questions the evidence -- though perhaps the problem is we use the wrong scale to identify patients who will benefit.
• There is also evidence for pentoxyfiline, though deciding who should get this over steroids, or if they would be better in combination is still pending.
  

I have previously talked about cirrhosis and advanced cirrhosis.