A podcast titled Tasty Morsels of Critical Care, from Emergency Medicine Ireland, focused on hepatorenal syndrome in its 73rd episode.
Typically, hepatorenal syndrome is an indicator of serious kidney damage, and is defined as a collection of signs and symptoms that primarily affect the kidneys and the liver. Generally, acute kidney injury is present in hepatorenal syndrome, along with cirrhosis and portal hypertension affecting the liver.
A diagnosis of hepatorenal syndrome is present if symptoms remain after the withdrawal of possible nephrotoxins (substances that damage the kidneys), ‘a decent trial of albumin,’ and treatment of any possible infections. The diagnosis also must exclude any intrinsic kidney diseases.
The syndrome can be categorized as an acute, or type I, form, in which creatinine levels increase rapidly, or the chronic, type II form, with creatinine levels that are rising, but slowly and steadily.
A rapid increase in creatinine is a sign of sudden kidney failure.
Associated Conditions and Diseases
Hepatorenal syndrome constitutes a medical emergency and is often associated with cirrhosis, in which the tissue of the liver is progressively damaged and turned to scar tissue. It’s especially prevalent in cirrhosis linked to alcohol abuse. However, it can also appear in fulminant liver failure. It can even be triggered by treatments for complications of liver disease. Other associated conditions can include bacterial peritonitis (infection of the ascites fluid) and bleeding in the upper gastrointestinal tract.
Management
Prevention of hepatorenal syndrome is a high priority for at-risk individuals, as risk of death is very high. Diuretic medicines should be avoided, and physicians must account for the potential adverse effects of therapies used to address cirrhosis. The principal treatment is liver transplant, and all other therapeutic approaches should be considered ‘bridge therapies’ towards this eventual goal. Even with transplant, the mortality rate can be as high as 25% in the first month.
Other treatments include:
- A combination of octreotide and midodrine
- Vasopressin analogues, such as ornipressin and terlipressin
- Transjugular intrahepatic portosystemic shunt
- Liver dialysis
- Kidney replacement therapy, such as dialysis
