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syndrome
June 6, 2006
Chief Complaint
“My eyes are yellow”
HPI
DW is a 42 yo male
Presented to local clinic
Jaundiced 2-3 weeks
Worsened the day of presentation
Lethargic and weak
No confusion
PMH
Hypertension
Asthma
Alcohol Abuse
Started in early 20’s
For the last 12-15 years has consumed a
bottle or more of vodka daily
Social and Family History
Lives with girlfriend and two children
Carpenter
Denies smoking
90
80
70
60
50
40
30
20
10
0
04/27/2006
04/28/2006
04/29/2006
04/29/2006
04/30/2006
05/01/2006
05/02/2006
05/03/2006
05/03/2006
05/04/2006
05/05/2006
05/05/2006
05/09/2006
05/17/2006
05/26/2006
BUN and Creatinine
BUN
CREATININE CREATININE
Child-Turcotte-Pugh =
Class C
MELD Score = 40
Hypotension-induced activation of
renin-angiotensin and sympathetic
nervous system.
Inappropriate constriction of the small
arteries in the kidney
Pathogenesis
Splanchnic vasodilation
Nitric oxide
Renal vasoconstriction
Tromboxane to prostaglandin ratio
20-HETE
Endothelin
False neurotransmitters
The Evidence
Ornipressin
Analog of antidiuretic hormone
Decreases norepinephrine
concentrations
Elevates mean arterial pressure
Type 2 HRS
Diuretic resistant ascites and/or edema
Incidence
In adult patients with hepatic failure,
ascites, and GFR >50 mL/min
20% develop HRS within the first year
40% by 5-year
Type 2
Expected median survival 6 months
Child Pugh C worse than B
Overall Mortality 80-95%
Precipitants
Gradual or Acute
Bacterial infection
Spontaneous bacterial peritonitis (20%)
Large volume (>5L) paracentesis w/o
plasma expansion (15%)
GI bleeding (10%)
Intravascular volume depletion ??
Diagnosis
Criteria from International
Advanced hepatic Ascites
failure Club
and portal
hypertension
Serum Creatinine >1.5 mg/dL or 24 CCl
<40ml/min
Exclusion of other disorders that can cause
Renal Failure
Urine Na <10 mEq/L, urine osmolality >plasma
osmolality, Na excretion <500mg/day
No improvement in renal function after 1.5L NS
and discontinuation of diuretics.
Proteinuria <500mg/dl
Arroyo et al. Definition and diagnostic criteria of refractory
ascites and hepatorenal syndrome in cirrhosis. Hepatology.
Differential Diagnosis
Prerenal failure due to fluid loss
Infection
Acute tubular necrosis
Setting of developing failure
Shock
Hypovolemia
Nephrotoxic agents