Gastroenterology Hepatology

Liver transplantation: pretransplant management - hepatorenal syndrome

How can I be sure that the patient has hepatorenal syndrome?

Hepatorenal syndrome (HRS) presents with reduced urinary output and rising serum creatinine in patients with cirrhosis and ascites. A characteristic of HRS is that the clinical features fail to return to normal after volume expansion with intravenous colloid.

A tabular or chart listing of features and signs and symptoms

How can I confirm the diagnosis of hepatorenal syndrome?

To confirm a diagnosis of HRS:

  1. Administer intravenous fluids, such as 100 g of 25% albumin or 500 mL of 0.9 NaCl.

  2. Test urine for microscopy and culture.

What other diseases, conditions, or complications should I look for in patients with hepatorenal syndrome?

Hepatorenal syndrome must be distinguished by the following:

  1. From prerenal uremia by demonstrating lack of response to replenishing intravascular volume with colloid solutions

  2. Acute tubular necrosis

  3. Postrenal obstruction

What is the right therapy for the patient with hepatorenal syndrome?

All patients with HRS should receive daily volume expansion using albumin. Peripheral vasoconstrictors, such as midodrine, often given with octreotide, are probably effective, although the data are weak. Some data suggest that the vasopressin analogue terlipressin, given in conjunction with albumin, is effective in rapidly progressive HRS, although terlipressin is not an approved agent in the United States.

Hemodialysis is appropriate as short-term treatment in HRS.

Patients with HRS often need liver transplantation, after which kidney function may recover.

  1. Stop all nonsteroidal anti-inflammatory medicines.

  2. Avoid aminoglycosides, radiocontrast dye, and other nephrotoxins.

  3. Stop diuretics.

  4. Perform sonogram of kidneys to exclude extrarenal obstruction.

  5. Look for other precipitating events, such as covert gastrointestinal hemorrhage, or unrecognized infection: ascites, chest, urine.

What is the most effective initial therapy?

Effective therapy for HRS involves the following:

  1. Stop all nonsteroidal anti-inflammatory medicines.

  2. Avoid aminoglycosides, radiocontrast dye, and other nephrotoxins.

  3. Stop diuretics.

  4. Start intravenous albumin, octreotide, and oral midodrine.

  5. Consider hemodialysis in patients who fail to recover.

  6. Liver transplantation.

Listing of usual initial therapeutic options, including guidelines for use, along with expected result of therapy.

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A listing of a subset of second-line therapies, including guidelines for choosing and using these salvage therapies

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Listing of these, including any guidelines for monitoring side effects.

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How should I monitor the patient with hepatorenal syndrome?

Monitor serum creatinine and blood urea nitrogen daily.

What's the evidence?

Skagen, C. "Combination treatment with octreotide, midodrine and albumin improves survival in patients with type 1 and type 2 hepatorenal syndrome". J Clin Gastroenterol. vol. 43. 2009. pp. 680-5.

Sanyal, AJ. "A randomized, prospective, double-blind, placebo-controlled trail of terlipressin for type 1 hepatorenal syndrome". Gastroenterology. vol. 134. 2008. pp. 1360-8.

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