2/24/17 Intern Morning Report – Renal Failure in a Hospitalized Patient, Hepatorenal Syndrome

CC: shortness of breath

ID: 64 yo AA female with HTN, Child’s C MELD 23 Hepatitis C cirrhosis complicated by hepatic hydrothorax, and HCC s/p IA chemo with TACE presents with 2 weeks of shortness of breath, abdominal swelling, and decreased appetite.  Patient was recently hospitalized a few days prior to admission where she underwent a thoracentesis for her hepatic hydrothorax and received levofloxacin for possible pneumonia.  Upon arrival, patient underwent a 1.5L paracentesis with improvement in her respiratory complaints; however, her creatinine was noted to uptrend from a baseline of 1.2 to 2.0 on HOD #2.  Patient’s creatinine continued to rise throughout her hospital course despite withdrawal of all nephrotoxic agents, fluid resuscitation, and attempts to relieve any possible obstruction.  UA was bland with no evidence of active sediment, ascitic fluid did not show any evidence of spontaneous bacterial peritonitis.  Patient was determined to most likely have Type 1 hepatorenal syndrome (HRS).

creatinine-trend
Patient’s creatinine trend through hospitalization.  Red arrows denotes times of albumin administration for volume expansion.

Don’t forget:

  • Hepatorenal syndrome is a diagnosis of exclusion!
  • Diagnostic hepatorenal syndrome criteria in cirrhosis
    • cirrhosis with ascites
    • serum Cr > 1.5 mg/dl
    • absence of shock
    • no improvement of serum creatinine after at least 2 days with diuretic withdrawal and volume expansion with albumin (recommended dose of albumin is 1 g/kg of body weight per day up to a maximum of 100 g/day)
    • no current or recent treatment with nephrotoxic drugs
    • absence of parenchymal disease (defined to be proteinuria > 500 mg/day, microhematuria > 50 RBC/hpf, and/or abnormal renal US)
  • There are 2 types of HRS

capture


Pearls from morning report:

  • The FeNa in contrast-induced nephropathy is usually <1%.
  • The mainstay of treatment of HRS (terlipressin, norepinephrine, midodrine, octreotide, albumin) is to increase effective circulating volume to ultimately increase perfusion to the kidneys.
  • Renal replacement therapy (HD or CRRT) is usually offered only to those awaiting liver transplant as it serves as a bridge to therapy.

Random trivia:

Terlipressin, approved for use in various countries in Europe, is currently not FDA approved for use in the US; however, the CONFIRM Study (a multi-center, randomized, placebo-controlled, double-blind study to confirm the efficacy and safety of terlipressin in HRS 1) is a phase III trial currently underway to attempt to bring terlipressin to widespread use in the US and Canada.


Want to read more?

Renal Failure in Cirrhosis (New England Journal of Medicine)
Diagnosis, Prevention and Treatment of Hepatorenal Syndrome in Cirrhosis (Gut)


References: 

Nadim MK, Kellum JA, Davenport A, Wong F, et al. Hepatorenal syndrome: the 8th International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2012 ; 16(1):R23.

Runyon BA, Sterns RH, Forman JP. Hepatorenal syndrome. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on February 24, 2017)

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