HEPATORENAL SYNDROME (HRS)

Background:

• Patients with Ascites have up to a 40% probability of developing HRS

• Defined (in general) by a creatinine > 1.5 mg/dL and creatinine clearance < 40 ml/min

• Two varieties of HRS are identified;

  • Type I

    • Rapidly progressive

    • Creatinine > 2.5 mg/dL

    • Prognosis is poor

    • Median survival two weeks

  • Type II

    • More slowly progressive

    • Creatinine > 1.5 mg/dL

    • Better prognosis

• Treatment is largely supportive. Measures to prevent HRS in patients with ascites include

  • Avoid volume restriction (aggressive diuresis)

  • Avoid nephrotoxic agents (NSAIDS, Aminoglycosides)

  • Recognize SBP and treat

• Treatment:

  • Systemic vasoconstrictors (Ornipressin), volume expansion with Albumin

    • Not approved in US

  • TIPS

    • Needs to be validated in large trials

  • Renal vasodilators

    • Dopamine at Renal doses (2 mcg/kg/min)

    • Prostin (Misoprostil 200 mcg po bid)

    • Usually not effective

  • MARS (molecular adsorbent recirculating system) (see article)

  • Liver Transplantation