Hepatorenal syndrome is an acute or subacute renal failure in patients with liver cirrhosis that has no identifiable cause. It develops due to portal hypertension which leads to splanchnic vasodilation, reducing effective circulatory volume and activating vasoconstrictor systems. This causes renal vasoconstriction and renal failure. Treatments include TIPS to reduce vasoconstriction, systemic vasoconstrictors, albumin, renal replacement therapy, and liver transplantation as the definitive treatment.

1. Hepatorenal Syndrome
Abdullah Almazyad

2. definition
•Development of an Acute or subacute renal
failure in a patient with liver cirrhosis ,
without an identifiable cause

3. Pathogenesis
•When patient develops Portal Hypertension , it leads to
splenic arterial vasodilation and pooling of blood into
splenic bed which decreases effective circulatory
volume and thus activation of Renin-angiotensin-
aldosterone system , sympathetic nervous system , and
antidiuretic hormone , with sodium and water
retention , vasoconstriction happens every where but
unfortunately splanchnic vessels respond poorly , with
reduction in renal vasodilators (prostaglandin and
Nitric oxide) , all of these mechanisms leads eventually
to development of RENAL VASOCOSTRICTION
•So called splanchnic steal phenomenon

4. Classification
•Type 1 : Acute development of renal failure in
which serum creatinine doubles to greater
then 2.5 mg/dl within 2 weeks
•Type 2 : subacute development of renal failure
in which serum creatinine rises slowly and
gradually over several weeks or months

5. Diagnostic Criteria
Major
Patient is confirmed to have cirrhosis with ascites
•Serum creatinine higher then 1.5
•No improvement with serum creatinine after at least 2 days with
diuretic withdrawl and volume expansion with albumin
•Abscense of shock
•No current or recent treatment with nephrotoxic drugs
•Abscens of parynchemal renal disease as indicated by : -Protenuria
more then 500 mg/day
-microhematuria (50 RBCs per power field)
-Abnormal renal ultrasound

6. Minor
•Urine Volume less then 500 ml/24h
•Urine sodium less then 10mEq/L
•Urine osmolality greater then plasma osmolality
•Serum sodium less then 130mEq/L

8. Treatment
•TIPS
•Systematic Vasoconstrictors
•Renal Vasodilators
•Albumin
•Renal Replacement Therapy
•Liver Transplantation

9. TIPS- Trsnjagular Intrahepatic Porto
systematic Shunt
•Significant suppression of vasoconstrictor
system
•Decrease creatinine level
•Control Ascites

10. Systematic Vasoconstrictor
•Medodrine (Alpha 1 agonist)7.5 mg orally 3
times per day/Octerotide (Somatostatin
analog)100 microgram SC 3 times daily
•Norepinephrine(beta 2 and alpha 2 agonist)
0.5-3mg continuous IV infusion until Cr is less
then 1.5mg/dl
•Terlipressin (Vasopressin agonist)0.5-1mg
every 4-6 hours IV until Cr is less then 1.5

11. Renal Vasodilators
•Prostaglandin E1
•Endothelin A
•Dopamine
•ACEI
Because of their adverse effect and lack of
benefit , they have been abounded

12. Albumin
•1 mg/kg IV in first day , followed by 20-40 mg
daily
•Should be given with systematic
vasoconstrictors

13. Response to therapy
•Slowly progressive reduction in Cr
•Increase in arterial pressure
•Increase in urine volume
•Increase in serum sodium concentration

14. Renal Replacement Therapy
•For patient who don’t respond to
vasoconstrictor therapy
•Peritoneal dialysis is better tolerated by
cirrhotic patient then Hemodialysis because it
enables removal of ascetic fluid and doesn’t
expose patient to anticoagulant while at the
same time fulfill criteria for renal support

15. Liver Transplantation
•The definitive therapy

16. Prophylaxis
•Patient presented with spontaneous bacterial
peritonitis should receive Albumin therapy ,
because it decreases the incidence of
Hepatorenal Syndrome
•Pentoxifylline : works by inhibits
phosphodiesterase , thereby improves blood
flow by increasing erythrocyte and leukocyte
flexibility