=====Hepatorenal Syndrome===== *end-stage result of poor renal perfusion induced by increasingly severe hepatic injury. *usually portal hypertension due to cirrhosis, severe alcoholic hepatitis, or, less often, metastatic tumors *diagnosis of exclusion and associated with poor prognosis *Arterial vasodilation in the splanchnic circulation, which is triggered by portal hypertension, seems to be central to renal deterioration *widespread vasodilation (esp splanchnic) leads to activation of renin-angiotensin and sympathetic nervous system thereby causing //**intense renal vasoconstriction**// *Often triggered by intercurrent illness - bacterial infection, GI bleeding etc ***Type I** - Worst prognosis - Creatinine generally double normal ***Type II** - milder rise in creatinine but ascites resistant to diuretics **International Ascites Club** criteria for a diagnosis of hepatorenal syndrome. [[https://rarediseases.org/rare-diseases/hepatorenal-syndrome/]] Major criteria are: *the presence advanced liver failure with portal hypertension *high levels of creatine (an organic acid) *absence of other causes of renal failure such as bacterial infection, shock, and the use of drugs that are toxic to the kidneys *no improvement in renal function with the withdrawal of diuretics and expansion of plasma with albumin (a protein made in the liver which is low in patients with liver disease) *low levels of protein in the urine with no evidence of a disease of the urinary disease (uropathy) or parenchymal renal disease. ==Presentation== *progressive rise in serum creatinine *normal urine sediment usually *No or minimal proteinuria (less than 500 mg per day) *very low rate of Na+ excretion (ie. urine Na+ concentration frequently <10 mEq/L) *may be oliguric, but may be normal early on ==Management== *usually aimed at improvement in liver function rather than renal *renal improvement involves use of NorAdrenaline or Terlipressin depending in severity of CVS compromise *careful fluid resuscitation *portocaval shunt in those who do not respond to medical management ---- **References include**\\ https://www.uptodate.com/contents/hepatorenal-syndrome\\