My EM Notes

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

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.

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

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