CURRENT Essentials of Critical Care.pdf

Chapter 14 Renal Disorders 209Hepatorenal Syndrome■ Essentials of Diagnosis• Acute renal failure in conjunction with preexisting liver dysfunction:advanced cirrhosis, severe alcoholic hepatitis, fulminantliver failure• Hyperbilirubinemia, coagulopathy, encephalopathy• Often with stigmata of portal hypertension: varices, ascites• Absence of shock, bacterial infection, nephrotoxic agents• Reduced urine output but rarely anuric• Reduced urinary sodium excretion with FE Na 1%• Unresponsive to fluid challenge or withdrawal of diuretics• Due to severe vasoconstriction of renal arteries accompanied byextrarenal arterial vasodilation, hypotension• Precipitated by gastrointestinal bleed, spontaneous bacterialperitonitis (SBP), excessive diuresis■ Differential Diagnosis• Volume depletion: diuretics, bleeding• Cardiac pump failure• Obstructive uropathy• Acute tubular necrosis: sepsis, prolonged hypoperfusion• Drug toxicity: NSAIDs, aminoglycosides, contrast• Autoimmune glomerulonephritis: vasculitis, cryoglobulinemia■ Treatment• Restore volume with albumin or blood to euvolemic state• Treat infection including SBP• Splanchnic vasoconstrictors have some reported success: vasopressin,norepinephrine, midodrine combined with octreotide• Peritoneal jugular shunt (LeVeen) benefits not well established;transjugular intrahepatic portosystemic shunt (TIPS) with someanecdotal benefit• Hemodialysis and ultrafiltration• Prevention: avoid nephrotoxins, excess diuresis, large-volumeparacentesis• Administration of albumin and antibiotics reduces likelihood renalimpairment in setting of SBP■ PearlRenal failure in HRS is “functional”; kidneys transplanted from patientswith HRS may resume normal function in the recipient, and renalfunction returns to normal when patients with HRS undergo livertransplantation.ReferenceKramer L et al: Hepatorenal syndrome. Semin Nephrol 2002;22:290. [PMID:12118394]