Summary about Disease
Hepatorenal syndrome (HRS) is a life-threatening medical condition that consists of rapidly developing renal failure occurring in individuals with advanced liver disease (cirrhosis, fulminant hepatic failure) and/or portal hypertension. It is characterized by intense renal vasoconstriction and reduced kidney blood flow, leading to impaired kidney function. HRS is typically triggered by complications of liver disease, such as spontaneous bacterial peritonitis (SBP), gastrointestinal bleeding, or large-volume paracentesis without adequate albumin replacement. There are two main types: HRS-AKI (acute kidney injury) and HRS-CKD (chronic kidney disease). HRS is a functional renal impairment, meaning the kidneys themselves are structurally normal but not functioning properly due to abnormal blood flow.
Symptoms
Symptoms of hepatorenal syndrome often develop quickly and can include:
Decreased urine output (oliguria)
Swelling in the abdomen (ascites)
Confusion or altered mental status (hepatic encephalopathy)
Fatigue
Jaundice (yellowing of the skin and eyes)
Nausea and vomiting
Weakness
General ill feeling
Causes
The primary cause of HRS is severe liver disease, leading to:
Portal hypertension: Increased pressure in the portal vein, which carries blood from the digestive organs to the liver.
Splanchnic vasodilation: Widening of blood vessels in the abdominal organs (splanchnic circulation), leading to decreased blood volume reaching the kidneys.
Reduced effective arterial blood volume: Despite normal or increased total blood volume, the amount of blood effectively perfusing organs like the kidneys is decreased.
Triggering Events: Infections like SBP, GI bleeding, or large-volume paracentesis without albumin replacement can worsen the condition.
Cirrhosis: Scarring of the liver due to long-term damage
Medicine Used
The primary goal of medical treatment is to improve liver function and blood flow to the kidneys. Medications may include:
Vasoconstrictors: Terlipressin, norepinephrine, or midodrine (with octreotide) to constrict blood vessels in the splanchnic circulation and improve kidney blood flow.
Albumin: To expand blood volume and improve blood pressure.
Diuretics: May be used cautiously to manage ascites but must be carefully monitored to avoid further kidney injury.
Antibiotics: If there is an infection (e.g., SBP).
Pentoxifylline- Shown to be beneficial in those with alcoholic hepatitis to reduce risk of hepatorenal syndrome
Is Communicable
No, hepatorenal syndrome is not a communicable disease. It is a complication of advanced liver disease and is not caused by an infectious agent.
Precautions
Preventing HRS involves managing underlying liver disease and avoiding triggers:
Manage liver disease: Follow medical advice for managing cirrhosis or other liver conditions.
Avoid alcohol and hepatotoxic medications: Reduce further liver damage.
Prevent infections: Practice good hygiene and seek prompt treatment for infections.
Judicious use of diuretics: Use diuretics carefully and under medical supervision.
Albumin replacement: Administer albumin after large-volume paracentesis.
Monitor kidney function: Regularly monitor kidney function, especially during hospitalizations or after procedures.
How long does an outbreak last?
HRS is not an outbreak-related disease. The duration of HRS depends on the underlying liver disease, the severity of the condition, and the response to treatment. It can develop rapidly (over days to weeks) and can be fatal if not treated promptly.
How is it diagnosed?
Diagnosis of HRS involves:
Clinical evaluation: Assessing the patient's history, symptoms, and physical examination findings.
Blood tests: To evaluate liver and kidney function (e.g., creatinine, bilirubin, liver enzymes).
Urine tests: To assess kidney function and rule out other causes of kidney injury.
Exclusion of other causes of kidney failure: Ruling out other causes of kidney injury, such as dehydration, medications, or intrinsic kidney disease.
Diagnostic criteria: Meeting specific criteria for HRS, which include advanced liver disease, kidney failure, absence of other causes of kidney failure, and lack of improvement in kidney function after volume expansion with albumin.
Measurement of urine Na can be helpful to determine if renal failure is pre-renal (BUN:Cr >20:1)
Liver Ultrasound or CT to assess for cirrhosis.
Timeline of Symptoms
The timeline of symptoms can vary, but generally:
Early stages: Subtle decreases in urine output, increased abdominal swelling, mild confusion.
Progression: Rapid decline in kidney function, marked oliguria, worsening ascites, increased confusion or hepatic encephalopathy.
Late stages: Severe kidney failure, coma, and potentially death if untreated. The progression can occur over days to weeks.
Important Considerations
HRS is a serious complication of advanced liver disease requiring prompt diagnosis and treatment.
Liver transplantation is the definitive treatment for HRS.
Medical management aims to stabilize the patient and improve kidney function until a liver transplant can be performed.
Early recognition and treatment of underlying liver disease and triggering events are crucial for preventing HRS.
HRS-AKI and HRS-CKD have different diagnostic criteria and management approaches.
The prognosis of HRS depends on the severity of the liver disease, the response to treatment, and the availability of liver transplantation.