8. Hepatorenal Syndrome:
Diagnostic Criteria
MAJOR CRITERIA:
Chronic/Acute liver disease with advanced hepatic failure and
portal hypertension
Low GFR (Creatinine>1.5mg/dL or CrCl<40ml/min)
Absence of shock, bacterial infection, nephrotoxin, GI /renal fluid
losses
No sustained renal improvement after withdrawing diuretics and
volume expansion (1.5 L NS)
Proteinuria<500mg/d and renal usg without obstruction or
parenchymal abnormality
MINOR CRITERIA
Urine Volume <500ml/day
Urine Na <10meq/L
Urine RBC<50/HPF
Serum Na <130meq/L
Hepatology. 1996 Jan;23(1):164-76
9.
10. Efferent and Afferent Arterioles of
Rabbit
100 100
AVP AVP
% Reduction in Lumen Diameter
90 90
NE NE
80 80
70 70
60 60
50 50
40 40
30 30
20 20
10 10
0 0
-14 -13 -12 -11 -10 -9 -8 -7 -6 -5 -14 -13 -12 -11 -10 -9 -8 -7 -6 -5
Agonist (Log M) Agonist (Log M)
Efferent Afferent
Edwards AJP 1989
13. Diclofenac Residues as the
Cause of Vulture population
Decline in Pakistan
Nature. 2004 Feb 12;427(6975):
14. ARF: Post-renal
Consider obstruction in every patient with ARF.
Sites of obstruction leading to ARF:
Bladder neck obstruction
Bilateral ureters
Urine volume variable.
Renal USG or
Bladder catheterization.
16. Atheroembolic disease
ARF precipitated by
angiography
Often eosinophilia and
low complement
Multi-organ dysfunction,
livedo reticularis, blue
toes
Generally irreversible
17. Acute Interstitial Nephritis
Triad of fever, skin rash
and eosinophilia
Eosinophiluria
Drugs: penicillin,
cephalosporins, diuretics,
NSAIDS, dilantin
Usually completely
reversible upon
withdrawing drug
?Glucocorticoids
25. Etiology of ATN
Ischemic
All pre-renal causes
Endogenous Exogenous Toxins
Toxins Antibiotics
Hemoglobin Contrast
Myoglobin Chemotherapy
Light chains Org. solvents,
Heavy metals
26. Radiocontrast Nephropathy
Clinical Course:
Onset of oliguria within 24 hours
Peak creatinine in 4-5 days followed by
recovery in the majority
Differential diagnosis: atheroembolic disease
Risk factors:
Age
Chronic kidney disease esp. diabetes
Pre-renal azotemia (e.g. cirrhosis, CHF)
Volume of contrast
27. Contrast Nephropathy Risk
S Creatinine> 0.5 mg/dl or > 25%at 48-72 h
Mehran R.. J Am Coll Cardiol. 2004 Oct 6;44(7):1393-9.
28. Heme Pigment Induced ATN
Rhabdomyolysis: traumatic or non-traumatic
Intravascular hemolysis
Mechanism uncertain: Vasoconstriction,
precipitation/obstruction, toxicity of other
breakdown products
Concomitant volume depletion
34. Treatment of ATN-2005
SUPPORTIVE CARE
• Acid-base/electrolyte balance
• Fluid balance
• Nutrition
• Review of drugs
• Dialysis:
• PD, HD, Continuous modalities
35. Intensity of Renal Support in Critically Ill
Patients with Acute Kidney Injury.
35 ml/kg/h
20 ml/kg/h
N Engl J Med. 2008 May 20. [Epub ahead of print]
39. Pathogenesis of ATN:
Reactive Oxygen Species
Source of ROS:
Xanthine
Dehydrogenase
NADH Oxidase
40. QUESTION: What preventive strategies
have been consistently shown to be effective
against ATN?
Maintaining euvolemia ?
N-acetyl cysteine ?
Dopamine ?
Iso-osmolar contrast ?
42. The Data
Effect on Mortality Friedrich JO; Adhikari N; Herridge MS; Beyene J.
Meta-analysis: low-dose dopamine increases urine output but does not prevent
renal dysfunction or death.
Ann Intern Med 2005 Apr 5;142(7):510-24.
Effect on need for Renal
Replacement Therapy
43. High-dose Furosemide for
Established ARF
338 pts with ARF on dialysis
Furosemide (25mg/kg IV or 35mg/kg PO, or
matched placebo) daily.
No difference in :
Survival
Renal recovery
Shorter time to 2L/day diuresis
Am J Kidney Dis. 2004 Sep;44(3):402-9
45. ARF Outcomes after Discharge:
Survival
979 pts who
received CRRT
69% in-hospital
mortality
Post discharge
survival:
6M: 89%
5 Y: 50%
Morgera, S. American Journal of Kidney Disease 2002; 40(2):275-279
46. ARF: Outcomes after Discharge
Quality of Life
77% assessed health as “Good to excellent”
69% resumed working
57% self-sustaining
Most Common Complaints:
Loss of energy
Difficulty with heavy housework
Limited physical mobility
Morgera, S. American Journal of Kidney Disease 2002; 40(2):275-279
Korkeila, M. Nephrology, Dialysis, and Transplantation 2000
52. Conclusions
ARF is common in hospitalized patients & has a
high mortality
A significant number of patients recover
The best (and least expensive) preventive
strategy is to maintain euvolumia
