Hepatorenal syndrome

Question: A 61 year old male with cryptogenic cirrhosis is in the ICU following a variceal bleed.  You are asked about starting treatment for HRS because his creatinine rose from a baseline of 1.2 on admission to 1.9 in 72 hours.  A urine sodium is < 10 and he has no intrinsic renal disease, determined by a bland sediment and two normal appearing kidneys on ultrasound.  That same ultrasound showed a nodular liver, splenomegaly and no ascites.  What should you recommend?

A. start midodrine empirically (as patient is already on octreotide for the variceal bleed) for HRS

B. recommend lasix to get those kidneys going!

C. ask team to perform a volume challenge; the diagnosis is probably HRS but you have to prove it first

D. encourage PO fluids and increase rate of IVF


Answer: Hepatorenal syndrome (HRS) occurs frequently with end stage liver disease and is a common cause of azotemia in the hospital setting.  Type 1 HRS is the more severe form, and progresses in days to weeks; type 2 HRS is more indolent, and progresses over weeks to months.

Some aspects in this case go hand in hand with the diagnosis of HRS type 1, including the creatinine rise and the low urinary sodium. The recent variceal bleed and splenomegaly suggests that this patient indeed has advanced liver disease. 

However, this patient does not have any ascites, and this negative finding should make you very wary about giving the diagnosis.  Are there any other likely explanations?  With the recent variceal bleed, a state of renal hypoperfusion  makes prerenal azotemia a likely bet.  Either way, your recommendation is to give more fluids, whether to officially rule out HRS or just to treat your suspicion of prerenal azotemia.

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