Hepatorenal Syndrome

Pt with h/o alcohol abuse, liver cirrhosis, portal HTN presents with elevated serum creatinine. Reports recent oliguria. No history suggestive of nephrotoxic drug use, shock, infection, significant recurrent fluid loss. Gynecomastia, hepatomegaly, caput medusa on exam.

• Obtain CBC, CMP, U/A, urine osmolality/sodium/protein; strict I&Os

• Serum sodium <130, creatinine >1.5, creatinine clearance <40

• U/A with <50 RBCs per HPF

• Urine osmolality > plasma osmolality, urine sodium <10

• No sustained improvement in renal function s/p discontinuation of diuretics, 1.5L isotonic saline bolus

• Renal U/S shows no evidence of obstruction/parenchymal disease

• Start midodrine 2.5mg IV and IV octreotide to achieve MAP increase of 15 mmHg or more

• Consider dopamine 2 mcg/kg/min IV to induce renal vasodilation

• Consider TIPS to reduce portal HTN

• Pt advised to abstain from alcohol

• Pt counseled that median survival is 3-6 months

• Pt counseled that long-term therapy may involve liver transplant

Notes

• Hepatorenal syndrome = functional renal failure in cirrhotic patients in the absence of intrinsic renal disease

• Cirrhosis } portal hypotension } splanchnic vasodilation } decreased systemic circulation } renal vasoconstriction } decreased renal blood flow, GFR, urine output } azotemia } sodium/water retention

• Midodrine is an alpha-1 agonist

• MAP = mean arterial pressure = 1/3(systolic BP) + 2/3(diastolic BP)

• TIPS = transjugular intrahepatic portosystemic shunt