Hepatorenal Syndrome

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Clinician severity weight: HCC, Facility severity weight: MCC / Medical Necessity is also supported with this diagnosis.

Hepatorenal syndrome (HRS) is the development of renal failure in patients with:
• advanced chronic liver disease and, occasionally, fulminant hepatitis, who have
• portal hypertension, and
• ascites

AKI is established with KDIGO thresholds of dysfunction.

Kidneys often resume normal function following liver transplantation.

Three important and easily recognized risk factors are:
• low mean arterial blood pressure (< 80 mmHg),
• dilutional hyponatremia, and
• severe urinary sodium retention (urine sodium < 5 mEq/L)

Hepatorenal Syndrome may occur:
• spontaneously,
• associated with infections (particularly spontaneous bacterial peritonitis [SBP]),
• acute alcoholic hepatitis, or
• large-volume paracentesis without albumin replacement
• gastrointestinal bleeding, (however, AKI in this setting may be 2º to hypovolemic shock)

Hepatorenal Syndrome, by type
Type 1 HRS: rapid and progressive renal impairment commonly precipitated by spontaneous bacterial peritonitis (SBP). Occurs in approximately 25% of patients with SBP, despite rapid resolution of the infection with antibiotics. Without treatment, the median survival of patients with type 1 HRS is less than 2 weeks, and virtually all patients die within 10 weeks after the onset of renal failure.

Type 2 HRS: a moderate and stable reduction in GFR and commonly with relatively preserved hepatic function. Often diuretic-resistant. Median survival 3-6 months, longer than type 1 HRS, but shorter than cirrhosis and ascites without renal failure.

Progressive liver failure, as manifested by worsening encephalopathy, jaundice and coagulopathy, is a preterminal condition if liver transplantation is not performed.

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