Hepatorenal Syndrome Follow-up

  • Author: Sandeep Mukherjee, MB, BCh, MPH, FRCPC; Chief Editor: Julian Katz, MD   more...
 
Updated: Jan 4, 2012
 

Further Inpatient Care

  • Every attempt should be made to establish a precipitating cause of HRS. This is particularly true for type 1 HRS, which rarely occurs spontaneously and may be associated with SBP in 25% of cases. If renal function does not improve after institution of third-generation cephalosporins for SBP, a follow-up diagnostic paracentesis is recommended 48 hours later.
  • Patients with HRS should be evaluated for liver transplantation. This may be more applicable for patients with type 2 HRS, who have a longer survival time, as opposed to patients with type 1 HRS, whose survival is extremely short and who may require alternative therapeutic methods (eg, TIPS, vasoconstrictors) as a bridge to transplantation.
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Further Outpatient Care

  • Patients with HRS need to be evaluated for liver transplantation. If they are not candidates, they have a poor prognosis and outpatient care will only be palliative in nature.
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Transfer

  • Patients diagnosed with HRS should be evaluated at a liver transplant center to determine if they are transplant candidates. Reasons for transferring patients include the following:
    • Assessment of candidacy for liver transplantation
    • Lack of facilities for performing dialysis at local/referring hospital
    • Entrance into study/treatment protocol for HRS at referral center
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Deterrence/Prevention

  • The main precipitating factor of type 1 HRS is SBP. When this develops in patients with type 2 HRS, the probability of developing type 1 HRS is very high. This may be prevented by antibiotic prophylaxis with Bactrim or fluoroquinolones in patients with a prior history of SBP. Alternatively, patients with type 2 HRS who are on the waiting list may benefit from prophylactic antibiotics, irrespective of whether they have a prior history of SBP.
  • A randomized controlled trial has shown that the incidence of SBP-related renal failure is reduced if these patients are treated with antibiotics and undergo plasma volume expansion with albumin (1.5 g/kg upon diagnosis and 1 g/kg 48 h later). The incidence of HRS in patients with SBP who received albumin together with antibiotic therapy was 10% compared with an incidence of 33% in patients who did not receive albumin; in addition, hospital mortality rates were also lower in patients who received albumin expansion.
  • LVP is considered another risk factor for the development of HRS, which may be prevented by the administration of albumin.
  • Patients who have cirrhosis with ascites have a 10% chance of developing HRS at 1 year and a 40% chance at 5 years. One alternative to treatment aimed at preventing HRS is performing liver transplantation in these patients before HRS develops, particularly because risk factors for the development of HRS have been identified. With the current donor shortage, this does not seem to be a realistic possibility.
  • In patients with acute alcoholic hepatitis, one study reported that the administration of pentoxifylline (400 mg tid for 28 d) reduced the incidence of HRS and mortality rates (8% and 24%, respectively) compared with a placebo group (35% and 46%, respectively). However, no long-term data exist on renal function or mortality rates in these patients.
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Complications

  • 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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Prognosis

  • Type 1 HRS has a median survival of 2 weeks, with few patients surviving more than 10 weeks.[16]
  • Type 2 HRS has a median survival of 3-6 months.
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Patient Education

  • Patients who have cirrhosis with ascites must be informed that they are at risk of developing HRS and they must be informed about the dismal prognosis this carries in the absence of liver transplantation. They should be very cautious when new medications are prescribed by physicians not familiar with their care and must avoid known nephrotoxic agents such as nonsteroidals and aminoglycosides. Any deterioration in their clinical condition should result in a prompt call to their physician to determine if they have developed HRS.
  • For excellent patient education resources, visit eMedicine's Hepatitis Center and Liver, Gallbladder, and Pancreas Center. Also, see eMedicine's patient education articles Cirrhosis and Liver Transplant.
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Contributor Information and Disclosures
Author

Sandeep Mukherjee, MB, BCh, MPH, FRCPC  Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center

Sandeep Mukherjee, MB, BCh, MPH, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Merck Honoraria Speaking and teaching; Ikaria Pharmaceuticals Honoraria Board membership

Coauthor(s)

Hemant K Roy, MD  Associate Professor of Medicine, Section of Gastroenterology, Feinberg School of Medicine at Northwestern University, Evanston-Northwestern Healthcare

Disclosure: Nothing to disclose.

Rowen K Zetterman, MD  Dean, Creighton University School of Medicine

Rowen K Zetterman, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Ann Ouyang, MBBS  Professor, Department of Internal Medicine, Pennsylvania State University College of Medicine; Attending Physician, Division of Gastroenterology and Hepatology, Milton S Hershey Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Oscar S Brann, MD, FACP  Associate Clinical Professor, Department of Medicine, University of California at San Diego; Consulting Staff, Mecklenburg Medical Group

Oscar S Brann, MD, FACP is a member of the following medical societies: American Gastroenterological Association

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

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