Hepatorenal syndrome

Male urinary system — The urinary system is made up of the kidneys, ureters, urethra and bladder.

Definition

Hepatorenal syndrome is a condition in which there is progressive kidney failure in a person with cirrhosis of the liver. It is a serious and often life-threatening complication of cirrhosis.

Causes, incidence, and risk factors

Hepatorenal syndrome occurs when there is a decrease in kidney function in a person with a liver disorder. Because less urine is removed from the body, nitrogen-containing waste products build up in the bloodstream (azotemia).

The disorder occurs in up to 10% of patients hospitalized with liver failure. It is caused by the mounting effects of liver damage and leads to kidney failure in people with:

Acute liver failure
Alcoholic hepatitis
Cirrhosis

Risk factors include:

Blood pressure that falls when a person rises or suddenly changes position (orthostatic hypotension)
Diuretic use
Gastrointestinal bleeding
Infection
Recent abdominal fluid tap (paracentesis)

Symptoms

Abdominal swelling due to fluid (called ascites, a symptom of the underlying liver disease)
Change in mental status
Coarse muscle movements or mucle jerks
Dark-colored urine (a symptom of the underlying liver disease)
Decreased urine production
Nausea and vomiting
Weight gain
Yellow skin (jaundice, a symptom of the underlying liver disease)

Signs and tests

This condition is diagnosed when other causes of kidney failure are ruled out by the appropriate tests.

A physical examination does not directly reveal kidney failure. However, the exam will usually show signs of chronic liver disease:

Confusion (often due due to hepatic encephalopathy)
Excess fluid in the abdomen (ascites)
Jaundice
Other signs of liver failure

Other signs include:

Abnormal reflexes
Decreased testicle size
Dull sound in the abdomen when tapped with the tips of the fingers, and visible fluid wave when examined by feel
Increased breast tissue (gynecomastia)
Sores (lesions) on the skin

The following may be signs of kidney failure:

Absent or low urine production, less than 400 cc/day
Fluid retention in the abdomen or extremities
Increased BUN and serum creatinine levels
Increased urine specific gravity and osmolality
Low serum sodium
Very low urine sodium concentration

The following may be signs of liver failure:

Abnormal prothrombin time (PT)
Increased serum ammonia levels
Low serum albumin
Paracentesis shows ascites
Signs of hepatic encephalopathy (an EEG may be performed if such signs are present)

Treatment

Treatment aims to improve liver function and ensure that there is enough blood volume in the body and that the heart is pumping it adequately.

The disorder is generally treated in the same way as kidney failure from any other cause.

All unnecessary medicines should be stopped, especially the antibiotic neomycin, ibuprofen and other NSAIDs, and diuretics ("water pills").
Dialysis may improve symptoms.
Medications such as octreotide plus midodrine, albumin, or dopamine may be used temporarily to improve kidney function.
A nonsurgical shunt (known as TIPS) is used to relieve the symptoms of ascites and may help kidney function. Surgery to place a shunt (called a Levine shunt) from the abdominal space (peritoneum) to the jugular vein may also relieve some of the symptoms of kidney failure. Both procedures are risky and proper selection of patients is very important.

Expectations (prognosis)

The predicted outcome is poor. Death usually occurs as a result of secondary infections or hemorrhage.

Complications

Bleeding
Damage to, and failure of, many organ systems
End-stage kidney disease
Fluid overload with congestive heart failure or pulmonary edema
Hepatic coma
Secondary infections

Calling your health care provider

This disorder most often is diagnosed in the hospital during treatment for a liver disorder.

References

Garcia-Tsao G. Cirrhosis and its sequellae. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier. 2007: chap 157.

Schuppan D, Afdhal NH. Liver cirrhosis. Lancet. 2008;371:838-851.

Disease

Hepatitis

Hepatitis is swelling and inflammation of the liver. It is not a condition, but is often used to refer to a viral infection of the liver.
Disease

Acute kidney failure

Acute (sudden) kidney failure is the sudden loss of the ability of the kidneys to remove waste and concentrate urine without losing .
Symptoms

Urine output - decreased

Decreased urine output is defined as producing less than 500 milliliters of urine in 24 hours.
Test

Abdominal tap

An abdominal tap is a procedure used to remove fluid from the area between the belly wall and the spine. This space is called the abdominal cavity.
Disease

Liver disease

The term “liver disease” applies to many diseases and disorders that cause the liver to function improperly or stop functioning. Abdominal pain, yellowing of the skin or eyes (), or abnormal results of suggest you have liver disease. See also:
Disease

Cirrhosis

Cirrhosis is scarring of the liver and poor liver function. It is the final phase of chronic .
Disease

End-stage kidney disease

End-stage kidney disease is the complete, or almost complete failure of the kidneys to function. The main function of the kidneys is to remove wastes and excess water from the body.
Disease

Pulmonary edema

Pulmonary edema is an abnormal build up of fluid in the air sacs of the lungs, which leads to shortness of breath
Disease

Hepatic encephalopathy

Hepatic encephalopathy is a worsening of brain function that occurs when the liver is no longer able to remove toxic substances in the blood.
Disease

Prerenal azotemia

Prerenal azotemia is an abnormally high level of nitrogen-type wastes in the blood.
Disease

Heart failure

Heart failure, also called congestive heart failure, is a condition in which the heart can no longer pump enough blood to the rest of the body.

Review date:: May 4, 2010
Reviewed by:: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine; George F. Longstreth, MD, Department of Gastroenterology, Kaiser Permanente Medical Care Program, San Diego, CA. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

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