Clinical Guideline For The Management Of Hepatorenal Syndrome

Document Title
Type of document
Brief summary of contents
Executive Director responsible for
Clinical Guideline:
Directorate / Department responsible
(author/owner):
CLINICAL GUIDELINE FOR THE
MANAGEMENT OF HEPATORENAL
SYNDROME
Clinical
CLINICAL GUIDELINE FOR THE
MANAGEMENT OF HEPATORENAL
SYNDROME
Medical Director
Dr Bill Stableforth
Contact details: 01872252722
Date original version written:
Date revised:
This document replaces (exact title of
previous version):
Approval route (names of
committees)/consultation:
Divisional Manager confirming approval
processes
Name and Post Title of additional
signatories
Equality Impact Assessment appended
Approval must not be given if the EIS is
not attached
Signature of Executive Director giving
approval
Publication Location (refer to Policy on
Policies – Approvals and Ratification):
Document Library Folder/Sub Folder
New Document
Bill Stableforth
Hyder Hussaini.
{Original Copy Signed}
Yes
{Original Copy Signed}
Internet & Intranet Intranet Only X
Clinical/ Gastroenterology
Date of final approval: 20 th February 2012
Date guideline becomes live: 20 th February 2012
Date due for revision: 1 st February 2015
Links to key external standards
EASL clinical practice guidelines on
the management of
ascites, spontaneous bacterial

peritonitis, and hepatorenal
syndrome in cirrhosis
http://www.easl.eu/assets/application/files/21e
21971bf182e5_file.pdf
Related Documents:
Suggested Keywords:
Training Need Identified?
Renal failure, hepatorenal syndrome, ascites,
cirrhosis, SBP
NO.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
This version supersedes any previous versions of this document.
All or part of this document can be released under the Freedom of Information Act
2000
This document is to be retained for 10 years from the date of expiry.
Clinical Guideline Template
Version No: 2.0
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CLINICAL GUIDELINE FOR THE MANAGEMENT OF
HEPATORENAL SYNDROME
1. Aim/Purpose of this Guideline
1.1. This guideline applies to clinical staff managing patients with hepatorenal
syndrome.
2. The Guidance
Definition of hepatorenal syndrome
The major criteria for the diagnosis of Hepatorenal syndrome are:
Cirrhosis with ascites
An abnormal or worsening Creatinine with oliguria
No improvement in Creatinine after at least 2 days of diuretic withdrawl and volume
expansion with albumin
Absence of shock, nephrotoxic drugs and parenchymal renal disease
Mechanism
Renal ischaemia due to:
reduced intravascular volume
systemic hypotension secondary to increased peripheral vasodilatation
splanchnic vasodilatation with reduced renal perfusion
dysfunctional renal microvascular autoregulation
Classification
Type 1 HRS :rapid progressively rise in serum creatinine secondary to precipitating
cause(90% mortality):
SBP/Sepsis
GI bleed
Diuretic treatment
Type 2 HRS: chronic renal impairment often associated with refractory ascites-rx for
ascites
Clinical Guideline Template
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Treatment (type 1 only)
Stop any nephrotoxic drugs such as: aminoglycosides (best avoided in patients with
liver disease) NSAIDs and diuretics and ACE inhibitors
Treat sepsis:
culture: sputum, urine, blood ascitic fluid, CXR
ascitic tap (Total WCC count > 0.5 = SBP)
The majority of patients with hepatorenal syndrome should be started on antibiotics
even in the absence of definite sepsis
Tazocin (4.5g tds) or IV
Initial IV human albumin solution (20%)
70 kg 6x 20% albumin daily
IV fluids according to hydration (N saline/4.5 %human albumin solution/blood)
Start terlipressin once optimal hydration
If persistent systemic hypotension consider HDU
Terlipressin
Use terlipressin with caution if history of ischemic heart disease or peripheral
vascular disease- discuss with senior.
70kg 2 mg QDS
treat for 14 days or when creatinine falls to baseline
daily infusion of HAS 20% : 200-400ml day (depend on body weight) and serum
albumin (< 30g/dl)
General points
hourly urine measurement
renal ultrasound/Urine dip
Consider Central line and HDU admission
avoid 5% dextrose infusions as may worsen hyponatremia
limited paracentesis if tense ascites only
The role of CVVH or Haemodialysis is very limited
Discuss with gastroenterologist /Hepatologist re. referral for liver transplant
Clinical Guideline Template
Version No: 2.0
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.
3. Monitoring compliance and effectiveness
3.1. see below 3.2
3.2. Compliance and effectiveness will be demonstrated by audit of care of
patients with HRS on Carnkie ward. KPI = mortality
4. Equality and Diversity
4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service
Equality and Diversity statement.
4.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 1.
Clinical Guideline Template
Version No: 2.0
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Appendix 1.Initial Equality Impact Assessment Screening Form
Name of service, strategy, guideline, policy or project (hereafter referred to as policy)
to be assessed: CLINICAL GUIDELINE FOR THE MANAGEMENT OF
HEPATORENAL SYNDROME
Directorate and service area:
Medical
Name of individual completing
assessment: BILL STABLEFORTH
Is this a new or existing Procedure?
Telephone:
01872252722
NEW
1. Procedure Aim* TO SET A STANDARD OF CARE FOR PATIENTS WITH
HEPATORENAL SYNDROME AT RCHT
2. Procedure Objectives* OMPROVE OUTCOME FOR PATIETS WITH
HEPATORENAL SYNDROME
3. Procedure – intended
Outcomes*
IMPROVE OUTCOME OF PATIENTS WITH
HEPATORENAL SYNDROME
4. How will you measure
the outcome?
5. Who is intended to
benefit from the
Procedure?
6a. Is consultation
required with the
workforce, equality
groups etc. around this
procedure?
AUDIT OF PATIENTS ON CARNKIE WARD
PATIENTS WITH HEPATORENAL SYNDROME DUE TO
ADVANCED LIVER DISEASE
NO
b. If yes, have these
groups been consulted?
c. Please list any groups
who have been consulted
about this procedure.
*Please see Glossary
Clinical Guideline Template
Version No: 2.0
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7. The Impact
Please complete the following table using ticks. You should refer to the EIA guidance
notes for areas of possible impact and also the Glossary if needed.
Where you think that the policy could have a positive impact on any of the equality
group(s) like promoting equality and equal opportunities or improving relations
within equality groups, tick the ‘Positive impact’ box.
Where you think that the policy could have a negative impact on any of the equality
group(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.
Where you think that the policy has no impact on any of the equality group(s) listed
below i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.
Equality
Group
Age
Positive
Impact
Negative
Impact
No
Impact
X
Reasons for decision
Disability
X
Faith and
Belief
X
Gender
X
Race
X
Sexual
Orientation
X
You will need to continue to a full Equality Impact Assessment if the following have
been highlighted:
A negative impact and
No consultation (this excludes any policies which have been identified as not
requiring consultation).
8. If there is no evidence that
the policy promotes equality,
equal opportunities or improved
relations - could it be adapted
so that it does? How?
Full statement of commitment to policy of
equal opportunities is included in the
guideline
Please sign and date this form.
Keep one copy and send a copy to the Human Resources Team,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department,
Lamorna House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ
They will arrange for a summary of the results to be published on the Trust’s web site.
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Version No: 2.0
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Signed ________________________________________
Date _________________________________________
Clinical Guideline Template
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