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Hepatorenal syndrome

 

Hepatorenal syndrome is a condition in which there is progressive kidney failure. It occurs in a person with cirrhosis of the liver. It is a serious complication that can lead to death.

Hepatorenal syndrome occurs when the kidneys stop working well in people with serious liver problems. Less urine is removed from the body, so waste products that contain nitrogen build up in the bloodstream (azotemia).

The disorder occurs in up to 1 in 10 patients who are in the hospital with liver failure. It 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)
  • Use of medicines called diuretics ("water pills")
  • Gastrointestinal bleeding
  • Infection
  • Recent abdominal fluid tap (paracentesis)

Symptoms

 

  • Abdominal swelling due to fluid (called ascites, a symptom of liver disease)
  • Mental confusion
  • Muscle jerks
  • Dark-colored urine (a symptom of liver disease)
  • Decreased urine production
  • Nausea and vomiting
  • Weight gain
  • Yellow skin (jaundice, a symptom of liver disease)

 

Exams and Tests

 

This condition is diagnosed after testing to rule out other causes of kidney failure.

A physical exam does not detect kidney failure directly. However, the exam will very often show signs of chronic liver disease, such as:

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

Other signs include:

  • Abnormal reflexes
  • Smaller testicle
  • Dull sound in the belly area when tapped with the tips of the fingers
  • Increased breast tissue (gynecomastia)
  • Sores (lesions) on the skin

The following may be signs of kidney failure:

  • Very little or no urine output
  • Fluid retention in the abdomen or extremities
  • Increased BUN and creatinine blood levels
  • Increased urine specific gravity and osmolality
  • Low blood sodium
  • Very low urine sodium concentration

The following may be signs of liver failure:

  • Abnormal prothrombin time (PT)
  • Increased blood ammonia levels
  • Low blood albumin
  • Paracentesis shows ascites
  • Signs of hepatic encephalopathy (an EEG may be done)

 

Treatment

 

The goal of treatment is to help the liver work better and to make sure the heart is able to pump enough blood to the body.

Treatment is about the same as for kidney failure from any cause. It includes:

  • Stopping all unnecessary medicines, especially ibuprofen and other NSAIDs, the antibiotic neomycin or gentamicin, and diuretics ("water pills")
  • Having dialysis to improve symptoms
  • Taking medicines such as octreotide plus midodrine, albumin, norepinephrine, or dopamine to improve blood pressure and help your kidneys work better
  • Placing a nonsurgical shunt (known as TIPS) to relieve the symptoms of ascites (this may also help kidney function, but the procedure can be risky)
  • Surgery to place a shunt (called a peritoneovenous shunt) from the abdominal space (peritoneum) to the jugular vein to relieve some symptoms of kidney failure (this procedure is risky and is rarely done)

 

Outlook (Prognosis)

 

The outcome is often poor. Death often occurs due to an infection or severe bleeding (hemorrhage).

 

Possible 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

 

When to Contact a Medical Professional

 

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

 

 

References

Garcia-Tsao G. Cirrhosis and its sequelae. In: Goldman L, Schafer AI, eds. Goldman's Cecil Medicine. 24th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 156.

Schuppan D, Afdhal NH. Liver cirrhosis. Lancet. 2008;371:838-851. PMID: 18328931 www.ncbi.nlm.nih.gov/pubmed/18328931.

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          Review Date: 5/15/2014

          Reviewed By: Jenifer K. Lehrer, MD, Department of Gastroenterology, Frankford-Torresdale Hospital, Aria Health System, Philadelphia, PA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.

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