Hepatorenal syndrome: Update on diagnosis and treatment

Table 1 Diagnostic criteria for hepatorenal syndrome

Cirrhosis with ascites

Serum Creatinine > 1.5 mg/dL

Absence of shock

No improvement of serum creatinine (decrease to a level of 1.5 mg/dL or less) after at least 2 d of diuretic withdraw and volume expansion with albumin (The recommended dose of albumin is 1 g/kg of body weight per day up to a maximum of 100 g/d)

No current o recent exposure to nephrotoxic drugs

Absence of parenchymal disease as indicated by proteinuria > 500 mg/d, microscopic hematuria (50 red blood cells per high power field) and abnormal renal ultrasonography

HRS: Hepatorenal syndrome.

Table 2 Characteristics of type I and type II hepatorenal syndrome

HRS I	Doubling of serum creatinine in < 2 wk	A precipitating event is present in the most of case	No history of diuretic resistant ascites	10% survival in 90 d without treatment
HRS II	Renal impairment gradually progressive	No precipitating events	Always ascites diuretic resistance	Median survival 6 mo

HRS: Hepatorenal syndrome.

Table 3 Risk factors for the onset of hepatorenal syndrome

Spontaneous bacterial peritonitis

Large volume paracentesis (> 5 L) with inadequate albumin substitution

NSAID and other nephrotoxic drugs, iv contrast

Bleeding from esophageal varices

Post TIPS syndrome

Diuretic treatment

Spontaneous bacterial peritonitis are leading trigger of HRS. One-third of patients with SBP develop HRS in the absence of septic shock. Diuretic treatment has been suggested as a potential trigger of HRS, but there are no clear supportive data for this. HRS: Hepatorenal syndrome; NSAID: Non-steroidal anti-inflammatory drug; TIPS: Transjugular intrahepatic portosystemic shunt.

Table 4 Differential diagnosis of renal failure in cirrhosis

Pre-renal	History of fluid loss, gastrointestinal bleeding, treatment with diuretics or non-steroidal anti-inflammatory drugs
Organic	Medical history, laboratory tests (cryoglobulinemia, complementemia, etc.)
Obstructive	Ultrasound imaging
Chronic kidney disease	Anemia, proteinuria, secondary hyperparathyroidism, ultrasound evidence of renal cortical thinning

Table 5 Prevention of hepatorenal syndrome and general patient management strategies

Avoid drugs that reduce renal perfusion or nephrotoxic substances

Minimize exposure to organ-iodated contrast agents

Intravenous albumin is recommended for volemic filling after large volume paracentesis (8 g of albumin for each liter of ascites removed)

Diuretic therapy should be suspended

Pentoxifylline as drug’s anti-TNFa activity

Antibiotic prophylaxis to prevent infections reducing intestinal bacterial translocation (norfloxacin 400 mg/d)

Intravenous albumin administered in association with ceftriaxone in SPB

Adrenal insufficiency should be identified and treated

Drug dosages must be adjusted according to renal function