Hrs mayeda 4_apr19

1. Noon Conference
Laura Mayeda
4/5/19

2. © 2016 Virginia Mason Medical Center
Overview
• Differential diagnosis AKI in cirrhosis
• Definitions of HRS
• Diagnosis
• Pathophysiology
• Treatment
• Prognosis
• Lessons learned

3. © 2016 Virginia Mason Medical Center
Differential diagnosis
Differential diagnosis for acute renal
failure in liver disease

4. © 2016 Virginia Mason Medical Center
Hepatorenal syndrome definition
• Low GFR, as indicated by serum Cr >1.5
mg/dl
• Absence of shock, ongoing bacterial
infection, fluid losses, and current
treatment with nephrotoxic drugs
• No sustained improvement in renal function
(decrease Cr ≤1.5 mg/dl) after diuretic
withdrawal and expansion of plasma
volume with 1.5 L of a plasma expander
• Proteinuria <500 mg/d and no
ultrasonographic evidence of obstructive
uropathy or parenchymal renal disease

5. © 2016 Virginia Mason Medical Center
Hepatorenal syndrome types
Type 1 hepatorenal syndrome
– least a twofold increase in serum
creatinine, >2.5 mg/dL during a period
of less than two weeks
– more severe type
Type 2 hepatorenal syndrome
– ascites that is resistant to diuretics
– less severe type

6. © 2016 Virginia Mason Medical Center
Question 1
What is the most common cause of
ARF in cirrhosis?
1) ATN
2) Prerenal
3) Hepatorenal syndrome type 1
4) Hepatorenal syndrome type 2

7. © 2016 Virginia Mason Medical Center
Question 1
What is the most common cause of
ARF in cirrhosis?
1) ATN
2) Prerenal
3) Hepatorenal syndrome type 1
4) Hepatorenal syndrome type 2

8. © 2016 Virginia Mason Medical Center
ATN is most likely cause of ARF
A multicenter, retrospective study of
423 patients with cirrhosis and ARF
cause of ARF is either ATN (35%) or
prerenal failure (32%). Types 1 HRS
(20%) are the cause of ARF (6.6%)

9. © 2016 Virginia Mason Medical Center
Diagnosis of HRS
• No diagnostic test
• Urinary neutrophil gelatinase-
associated lipocalin (NGAL) lower in
prerenal azotemia and HRS than ATN
• Diagnosis of exclusion
• No response to fluid challenge
suggest HRS over prerenal
• No sepsis/shock or nephrotoxic
agents suggest HRS over ATN
9

10. © 2016 Virginia Mason Medical Center
Question 2
What is the most common trigger for
hepatorenal syndrome in cirrhosis?
A)Infection
B)Worsening portal hypertension
C)Variceal bleeding
D)Worsening prerenal state
10

11. © 2016 Virginia Mason Medical Center
Question 2
What is the most common trigger for
hepatorenal syndrome in cirrhosis?
A)Infection
B)Worsening portal hypertension
C)Variceal bleeding
D)Worsening prerenal state
11

12. © 2016 Virginia Mason Medical Center
Pathophysiology
^RAAS ->
vasoconstriction ->
decrease GFR

13. © 2016 Virginia Mason Medical Center
Activation of RAAS

14. © 2016 Virginia Mason Medical Center
QUESTION 3
What is the correct synthesis location
of RAAS components? Renin-
Angiotensin-Aldosterone
A)Juxtaglomerular cells – lung - liver
B)Renal tubular cells – lung - adrenal
C)Lung – liver – renal collecting duct
D)Juxtaglomerular cells – liver –
adrenal

15. © 2016 Virginia Mason Medical Center
QUESTION 3
What is the correct synthesis location
of RAAS components? Renin-
Angiotensin-Aldosterone
A)Juxtaglomerular cells – lung - liver
B)Renal tubular cells – lung - adrenal
C)Lung – liver – renal collecting duct
D)Juxtaglomerular cells – liver –
adrenal

16. © 2016 Virginia Mason Medical Center
RAAS

17. © 2016 Virginia Mason Medical Center
Treatment
• First step is fluid challenge to see if
improves renal function (prerenal)
• Critically ill
• Norepi vasoconstricts
• Not critically ill
• Midodrine, octreotide, albumin
• Overall goal to interrupt splanchnic
vasodilation -> decrease renal
vasoconstriction

18. © 2016 Virginia Mason Medical Center
Prognosis is poor
Untreated type 1 HRS
– Mortality is as high as 80% in 2 wk
– 10% of patients survive >3 mo

19. © 2016 Virginia Mason Medical Center
Curbsiders Pearls
• Use of colloid over crystalloid for
fluid challenge
• Precipitants can be SBP, variceal
bleed
• Hypotension and definition of HRS
• MAP goals >90 for appropriate renal
perfusion

20. © 2016 Virginia Mason Medical Center
Lessons learned
• Severe alcoholic hepatitis can be
accompanied by hepatic
encephalopathy, variceal bleed,
ascites and HRS WITHOUT cirrhosis
• Prednisone contraindications include
HRS, variceal bleed, and infection
– Pentoxifylline is secondline treatment for
acute alcoholic hepatitis