=====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

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**References include**\\ 
https://www.uptodate.com/contents/hepatorenal-syndrome\\