35 36 37 (6) Hepatorenal Syndrome.docx

Hepatorenal Syndrome Learning Objectives For the following complications of cirrhosis, describe: Pathophysiology Non-pharmacologic management strategies Pharmacologic management strategies, including dosing Primary and secondary prophylaxis, including dosing, when applicable Complications: portal hy...

Hepatorenal Syndrome Learning Objectives For the following complications of cirrhosis, describe: Pathophysiology Non-pharmacologic management strategies Pharmacologic management strategies, including dosing Primary and secondary prophylaxis, including dosing, when applicable Complications: portal hypertension, varices, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome Hepatorenal Syndrome (HRS-AKI) Definition: functional renal impairment in the setting of liver disease; kidneys not receiving enough blood due to hepatic damage Often precipitated by SBP, systemic bacterial infections, and large volume paracentesis without volume expansion Pathophysiology Part 1 Pathophysiology Broken Down Portal hypertension causes splanchnic blood pooling Vasodilation occurs from increased vasodilator production Low circulating blood volume activates SNS, RAAS, release of vasopressin for potent vasoconstriction Leads to ↑CO and retention of Na/H2O, but kidneys still hypoperfused due to vasoconstriction Hepatorenal syndrome (HRS-AKI) Major criteria for diagnosis Cirrhosis with ascites Diagnosis of AKI After 2d of diuretic withdrawal & albumin 1g/kg daily, still in AKI Absence of shock No nephrotoxic drugs Absence of structural kidney disease General Treatment Recommendations Albumin 1 g/kg up to 100 g/day to prevent hepatorenal syndrome in patients with elevated SCr Hemodialysis or CRRT until transplant is often required Liver transplant may be required Pharmacologic Treatment Norepinephrine + albumin If unable to take PO Requires ICU setting Less data available in studies Terlipressin + albumin New approval in US Superior to albumin + octreotide + midodrine in very small studies (70.4% renal recovery vs. 28.6%) Not studied vs. norepinephrine $4000 per vial = 1 day of therapy Incidence of respiratory depression and hyponatremia Alternative: Albumin + Octreotide + midodrine Albumin 10-20g IV qdaily for 20 days + octreotide up to 200mcg SQ TID + midodrine up to 12.5-15 mg PO TID to achieve 15mmHg BP increase Superior to dopamine + albumin Can be given on the floor Dopamine + albumin (no longer preferred)