Hepatorenal Syndrome Definition expansion with albumin; the recommended dose of albumin is 1 g/kg of body weight per day

up to a Acute kidney injury in the context of cirrhosis or maximum of 100 g/d fulminant acute hepatic failure Absence of shock Type I: rapidly progressive acute renal failure, creatinine doubles in two weeks No current/recent tx with nephrotoxic drugs Type II: slow and progressive, creatinine increases Absence of parenchymal disease as indicated by and/or plateaus and does not exceed 180 mol proteinuria > 500 mg/d microhematuria (> 50 red blood cells per high-power field) and/or abnormal Pathogenesis: underfill theory renal ultrasonography Former criteria: oliguria, low urine sodium level, and high urine osmolality H&P No direct correlation between severity of liver disease and HRS Common precipitants: bacterial peritonitis (greatest risk factor), vomiting, diarrhea (lactulose), variceal bleeding, aggressive diuresis When to suspect: liver disease w ascites, dilutional hyponatremia, tachycardia, MAP<80 mmHg When to rule out: proteinuria, hematuria, abnormal urine sedimentation Same UA results as prerenal azotemia, abdominal compartment syndrome Differential: ATN, HBV or HCV membranous GN, cyclosporine toxicity, changes in immune or metabolic status Treatment Liver transplant only definitive treatment 50% response to medical therapy Goal: correct hypoalbuminemia, facilitate peripheral vasoconstriction Standard: terlipressin (V1 agonist, 4-6 mg/day) and albumin (0.5-1 mg IV every 4-6 hours) as treatment bridge Hyponatremia should be corrected with fluid restriction instead of diuresis Agents that vasodilate renal circulation will exacerbate HRS TIPS: Na excretion, plasma creatinine, may increase risk of hepatic encephalopathy Other potential treatments: octreotide, oral midrodrine, IV norepinephrine 20% recurrence rate, repeat treatment Correlated with good response: BL creatinine <5mg/dL, BL BR <10mg/dL, MAP 5 mmHg on day 3 Prevention: quinolone 1x/week for peritonitis prophylaxis, IV albumin 1.5 mg/kg body weight

Vasoactive mediators: PGI2, adenosine, NO Portal HTN endothelial shear stress Compromise of intestinal mucosal barrier bacteria infiltrate mesenteric lymph nodes release of cytokines and endotoxin splanchnic vasodilation Decreased RBF decreased GFR Na and water retention No evidence of direct link between portal circulation and renal circulation

Diagnosis **no definitive test, diagnosis of exclusion** Current diagnostic criteria Cirrhosis with ascites Serum creatinine > 133 mol/L (1.5 mg/dL) No sustained improvement of serum creatinine (decrease to a level of 133 mol/L or less) after at least 2 d of diuretic withdrawal and volume