RRI as diagnostic index

1. RRI as diagnostic and follow up
indicator in cirrhosis of the liver
with hepatorenal syndrome and
refractory ascites
by DR. K ANANYA
MODERATOR :DR KIRAN MD
Journal of The Association of Physicians of India : volume 67 :April 2019

2. INTRODUCTION
• Hepatorenal syndrome(HRS) is defined as unexplained kidney failure
in patients with liver disease due to renal vasoconstriction.
• The Renal resistive index(RRI) derived from intrarenal arterial doppler
is a non-invasive tool to know the extent of vasoconstriction.
• Large volume paracentesis is the first line therapy for refractory
ascites in cirrhosis patients but the dreaded complication of LVP is
Paracentesis induced circulatory dysfunction(PICD)

3. • Albumin is the commonly used plasma expander to reduce incidence
of PICD and to prevent HRS.
• In this study a combination of noradrenaline and albumin infusion
have been tried to increase the GFR and renal plasma flow in order to
improve renal function and reverse HRS.

4. • In a study done by Moshin et al it was seen that patients with RRI>
0.77 had massive ascites compared to patients with RRI<0.77,similar
findings are seen in studies done by Gotzberger et al, Celebi et al and
Rivolta et al.
• A study by Goyal et al revealed that patients with cirrhosis and ascites
have significantly increased RRI(0.72 +/-0.02) compared to cirrhosis
without ascites (0.62+/-0.06).

5. OBJECTIVES
1. To determine usefulness of RRI in diagnosis and follow up of HRS.
2. To determine if large volume paracentesis, noradrenaline and
albumin infusion can prevent patients from going into Hepatorenal
syndrome.
In this study we used LVP, Noradrenaline and albumin infusion for
treating cirrhosis with refractory ascites and HRS while monitoring with
RRI.

6. MATERIALS AND METHODS
• The study was a descriptive observational prospective study
conducted in MVJ Medical College and Hospital Hoskote,
Bangalore over a period of two years (2014 –2016).
• Duplex doppler ultrasound of renal arteries(interlobar and arcuate)
are done with fasting period of 4 hours prior to the ultrasound to
reduce masking by intestinal gas.

7. • The RRI was calculated with the formula
(peak systolic velocity – end diastolic velocity)/peak
systolic velocity
• LVP(4 lit) was done over 1-2 hrs, albumin(5g/L) was given
noradrenaline infusion rate adjusted to maintain SBP at 110 mmHg
for 24 hrs ,post paracentesis RRI was measured on day 2,day 7 and
after 2 months.

8. Inclusion criteria
• Patients > 18 years diagnosed to have cirrhosis of liver with refractory
ascites clinically and sonologically.
• Patients with RRI > 0.7

9. Exclusion criteria
• Patients with acute infections, cardiovascular instability, diabetes,
hypertension, suspected or overt malignancies.
• Patients with nephropathies, decreased kidney size or reduction of
renal parenchymal width and significant renal parenchymal hyper
echogenecity.
• Patients with peripheral vascular thrombosis, mesenteric vascular
thrombosis, INR>2 after repeated correction with FFP, hypotension,
hypersensitivity to adrenaline.

10. RESULTS

14. DISCUSSION
• Hepatorenal syndrome is a form of renal failure without renal
pathology that occurs in about 10% of patients with advanced
cirrhosis or acute liver failure.
• It represents the end – stage of a sequence of reductions in renal
perfusion induced by severe hepatic injury.

15. PATHOGENESIS
• Arterial vasodilation in the sphlanchnic circulation triggered by portal
hypertension plays key role in the hemodynamic changes and decline
in kidney function in cirrhosis.
• The presumed mechanism is increased production or activity of
vasodilators in the splanchnic circulation.

17. • As the hepatic disease progresses, there will be rise in cardiac output
and fall in systemic vascular resistance despite of local increase in
renal vascular resistance due to hypotension induced activation of
renin-angiotensin-aldosterone system and sympathetic nervous
system.
• The renal vasoconstriction causes decreased renal perfusion
associated with reductions in GFR and sodium excretion and fall in
mean arterial pressure.

18. CLINICAL FEATURES
• Hepatorenal syndrome is characterized by following features in a
clinically evident acute or chronic liver disease patient
a. A progressive rise in serum creatinine
b. An often normal urine sediment
c. No or minimal proteinuria(less than 500 mg per day)
d. A very low rate of sodium excretion (urine sodium concentration
less than 10 mEq/L)
e. Non oliguria or oliguria, depending upon the severity

19. • Based upon rapidity of decline in kidney function, there are two
forms of hepatorenal syndrome
1. Type 1 hepatorenal syndrome : It is defined as at least a twofold rise
in serum creatinine (reflecting 50% reduction in creatinine
clearance in 24 hrs <20 ml/min) to a level greater than 2.5 mg/dL
during a period of less than two weeks, some have urine output <
400 –500 ml per day, its severe type with high mortality with 10%
surviving more than 2 months.

20. 2. Type 2 hepatorenal syndrome : Patients satisfy the criteria of
HRS but renal failure doesn't progress rapidly as type 1.They
have relatively preserved hepatic function with refractory
ascites. survival is reduced compared ascites with normal
renal function.
• The onset of HRS is insidious but sometimes may be precipitated by
bacterial infection, GI bleeding, spontaneous bacterial peritonitis

21. DIAGNOSIS
• Hepatorenal syndrome is diagnosed based on clinical criteria, there is
no specific test
• It is a diagnosis of exclusion, meaning that other potential etiologies
of acute or subacute kidney injury in liver failure should be ruled out

22. • The following criteria are considered for diagnosis
Major criteria:
1. low glomerular filtration rate(serum creatinine> 1.5mg/dl or
creatinine clearance < 40 ml/min)
2. Absence of shock, ongoing sepsis, fluid loss, nephrotoxic drugs.
3. No sustained improvement in renal function after diuretic
therapy stopped and expansion of plasma volume with 1.5 lit of plasma
expander.
4. Proteinuria <500mg/day;no ultrasound evidence of renal tract
obstruction or renal disease.

23. Additional criteria(not necessary for diagnosis) :
1. Urine volume <500 ml/day.
2. Urine sodium <10 mmol/day.
3. Urine osmolarity >plasma osmolarity.
4. Urine red cells <50/high-power field.
5. Serum sodium <130mmol/l.

24. DIFFERENTIAL DIAGNOSIS
• Kidney injury associated with infection such as spontaneous bacterial
peritonitis.
• Diabetic Nephropathy
• Parenchymal kidney disease(such as glomerulonephritis)

25. TREATMENT
• The ideal treatment is management of cirrohsis and preventing its
complications by
Balanced diet with low salt intake(<2g/day) and protein intake of 1-
1.5 g/day.
Abstinence of alcohol
Effective antiviral therapy in viral hepatitis
Corticosteroids in autoimmune hepatitis
Interferon alpha and gama, antioxidants, colchicine
Diuretic therapy, salt and fluid restriction
Ursodeoxycholic acid to treat jaundice

26. Non selective Beta blockers like propanolol for primary prophylaxis of
variceal bleeding.
Octreotide and midodrine can also be used for prophylaxis of variceal
bleeding and also in HRS.
Endoscopic banding, sclerotherapy balloon tamponade are done for
bleeding varices.
Rifaximin, l-ornithine l-aspartate, lactulose are used in hepatic
encephalopathy.

27. • The management of HRS includes
1 .Noradrenaline (0.5 to 3 mg/hr) as continuous infusion with a goal
of raising mean arterial pressure by 10 mmHg and albumin(1g/kg/day
max 100g)for at least two days
2. Vasopressin may also be effective starting at 0.01 units/min
3. Terlipressin IV bolus (1 to 2mg every 4-6 hrs) and albumin for two
days.

28. 4. When terlipressin is not available a combination of midodrine,
octreotide and albumin are given.
5. Midodrine orally starting at 7.5mg and increasing the dose 8 th
hourly to a max of 15 mg (TID)
6. Octreotide by continuous IV infusion (50 mcg/hr) or
subcutaneously (100-200mcg TID)

29. • In Patients with serum creatinine > 1.5mg/dL even after 2 weeks of
medical treatment, Transjugular intrahepatic portosystemic shunt
may be considered but not feasible in all cases.
• In patients who fail to respond renal replacement therapy is done.
• Definitive treatment is liver transplantation.

30. • Refractory ascites can be defined as ascites that persists even with
maximum dose of diuretics(spironolactone 400-600mg/d and
furosemide 120-160mg/d) and salt restriction.
• Large volume paracentesis(4L or more) and albumin can be
considered in case of refractory ascites along with diuretics.

32. • In this study the cases are treated with LVP adrenaline and albumin
infusion while the controls are treated with salt restriction, diuretics
and aldosterone antagonists without further treatment.
• The results when monitored with RRI and eGFR, serum creatinine,
sodium and portal vein diameter are better improved in cases
compared to controls.
• No other studies have used RRI as diagnostic tool and follow up of
cirrhosis.
• The value of RRI > 0.7 is taken based on Goyal's study.

33. CONCLUSION
• RRI is an affordable, noninvasive and easily available tool that can be
included as part of evaluation in liver cirrhosis, early detection and
follow up of HRS.
• LVP with noradrenaline and albumin infusion is effective in treating
refractory ascites and to prevent HRS.

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36. Thank you